FORMULIR 2.B.

PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : JANUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317062501200002 Alvarendra Aqmar Rizqy L 25-01-2020 N 23 H √ √ √ √ x √ √ √ √ √
2 3317061402200001 Syafira Aida Zahra P 14-02-2020 S 22 M √ √ √ √ √ √ √ √ √ √
3 3317061403200001 Muhammad Alfan Amiqol Fahmi L 14-03-2020 N 22 H √ √ √ √ x √ √ √ x √
4 3317062203200001 Putri Khumaira Assifa P 22-03-2020 N 21 H √ √ √ √ x √ √ √ x √
5 3317061404200002 Zariatun Na'mah P 14-04-2020 N 20 H √ √ √ √ x √ √ √ x √
6 3317063004200002 Elva Aprilia Ramadhani P 30-04-2020 N 20 H √ √ √ √ x √ √ √ x √
7 Waji'atul Khusna P 03-07-2020 N 18 H √ √ √ √ x √ √ √ x √
8 Muhammad Ridho Rafian L 13-08-2020 N 17 H √ √ √ √ x √ √ √ x √
9 Nabila Asna P 25-08-2020 N 16 H √ √ √ √ x √ √ √ x √
10 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 16 H √ √ √ x x √ √ √ x √
11 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 15 H √ √ √ √ x √ √ √ x √
12 Azam Maulana Putra L 24-09-2020 N 15 H √ √ √ x x √ √ √ x √
13 Danis Ahmad Faisal L 25-09-2020 N 15 H √ √ √ x x √ √ √ x √
14 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 15 H √ √ √ x x √ √ √ x √
15 Asna Maulidya Putri P 29-11-2020 N 14 H √ √ √ x x √ √ √ x √
16 M.Ridwan Alfaris L 07-11-2020 N 14 H √ √ √ x x √ √ √ x √
17 3317060302210001 Muhammad Ubaidilah Majid L 03-12-2021 N 11 H √ √ √ x x √ √ √ x √
18 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 10 H √ √ √ √ x √ √ √ x √
19 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 10 H √ √ √ x x √ √ √ x √
20 Ahmad Farhan Alalifi L 23-02-2021 N 10 H √ √ √ x x √ √ √ x √
21 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 10 H √ √ √ x x √ √ √ x √
22 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 9 H √ √ √ x x √ √ √ x √
23 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 8 H √ √ √ x x √ √ √ x √
24 Yumna Ziyanada Kalisa P 28-04-2021 N 8 H √ √ √ x x √ √ x x √
25 M. Azmi Alfarizi L 18-05-2021 N 7 H √ √ √ x x √ √ x x √
26 Ahmad Mushollin L 19-06-2021 N 6 H √ √ √ √ x √ √ x x x
27 Maryam Eliza Khasanah P 27-06-2021 N 6 H √ √ √ √ x √ √ x x x
28 Niko Rafif Pratama L 19-07-2021 N 5 H √ √ √ √ x √ √ x x x
29 Laila Wasiatun Maghfiroh L 12-09-2021 N 4 H √ √ √ x x √ √ x x x
30 Muhammad Syadid L 13-09-2021 N 4 H √ √ √ x x √ √ x x x
31 Farel Ahmad Fatian L 18-09-2021 N 4 H √ √ √ x x √ √ x x x
32 Seva Tia Azzahra P 18-09-2021 N 4 H √ √ √ √ x √ √ x x x
33 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 3 H √ √ √ √ x √ √ x x x
34 3317062612190003 Muhammad Khizbun Naja P 26-12-2019 N 22 H √ √ √ √ x √ √ √ √ √
35 3317061402200000 Abdullah Syamikh L 14-02-2020 N 22 H √ √ √ √ x √ √ √ √ √
36 Ghibran Adidama Athalla L 31-05-2020 N 20 H √ √ √ √ x √ √ √ x √
37 Qiba Mufti L 13-07-2020 N 17 H √ √ √ x x √ √ √ x √
38 Asfa Azkiya Nahda P 19-12-2020 N 13 H √ √ √ x x √ √ √ x √
39 Zaidatul Khusna P 15-11-2020 N 13 H √ √ √ x x √ √ √ x √
40 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 11 H √ √ √ x x √ √ √ x √
41 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 9 H √ √ √ x x √ √ √ x √
42 Hilyatun Nisa P 20-10-2021 N 2 H √ √ √ x x √ √ x x x
43 3317062601200001 Hana Fadhilah P 26-01-2020 K 23 K √ √ √ √ √ √ √ √ x √
44 3317060103200002 Khaizul Ma'ali L 01-03-2020 N 22 H √ √ √ √ x √ √ √ x √
45 3317060805200001 Jazilatun Na'mah P 08-05-2020 N 20 H √ √ √ √ x √ √ √ x √
46 3317060106200002 M.Busrol Karim L 01-06-2020 N 19 H √ √ √ √ x √ √ √ x √
47 3317060206200002 M.Reihan Kamil L 02-06-2020 N 19 H √ √ √ √ x √ √ √ x √
48 3317066206200001 Nihayatun Nikmah P 22-06-2020 N 19 H √ √ √ √ x √ √ √ x √
49 3317062910200001 M.Fatin Kamil L 29-10-2020 N 14 H √ √ √ x x √ √ √ x x
50 3317067008200002 Siti Zulfa Zahra P 30-08-2020 N 17 H √ √ √ √ x √ √ √ x √
51 3317062709200001 M.Miftahul Huda L 27-09-2020 N 17 H √ √ √ √ x √ √ √ x √
52 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 17 H √ √ √ √ x √ √ √ x √
53 3317062911200001 M.Chasan Jamil L 29-11-2020 N 13 H √ √ √ x x √ √ √ x √
54 Fatimah Yaqut Fahriyani P 08-01-2021 N 12 H √ √ √ x x √ √ √ x √
55 3317066001210001 Fina Saadah P 20-01-2021 N 11 H √ √ √ x x √ √ x x √
56 3317061402210002 M. Idror L 14-02-2021 N 11 H √ √ √ x x √ √ x x √
57 3317062007210002 M. Fahriza Akbar L 05-15-2021 N 8 H √ √ √ x x √ √ x x √
58 Alifia Nazla Nurul Ilmi P 30-05-2021 N 7 H √ √ √ x x √ √ x x √
59 Muh. Asyraf Tsaquf L 07-07-2021 N 6 H √ √ √ x x √ √ x x x
60 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 4 H √ √ √ x x √ √ x x x
61 3317063101200001 Alawiya Wafa Afifah P 31-01-2020 N 23 H √ √ √ √ x √ √ √ √ √
62 3317061402200002 M.Azril Rafif Alfarizi L 14-02-2020 N 23 H √ √ √ √ x √ √ √ √ √
63 3317061803200001 M.Rifqi Abidin L 18-03-2020 N 22 H √ √ √ √ x √ √ √ √ √
64 3317060904200001 Amelia Safira P 09-04-2020 N 21 H √ √ √ √ x √ √ √ √ √
65 3317062904200002 Ahmad Naja Ramadhani L 29-04-2020 N 20 H √ √ √ √ x √ √ √ √ √
66 3317063104200001 M.Arfan Romadhon L 31-04-2020 N 20 H √ √ √ √ x √ √ √ √ √
67 3317062605200001 M.Zaki Alfarizqi L 26-05-2020 S 19 M √ √ √ √ √ √ √ √ √ √
68 3317062705200001 Naura Azka Almira P 27-05-2020 N 19 H √ √ √ √ x √ √ √ √ √
69 A.Shofiul Asmi Alashari L 26-07-2020 N 17 H √ √ √ x x √ √ √ x √
70 Nabila Zafira Andini P 17-09-2020 N 16 H √ √ √ x x √ √ √ x √
71 Nayyila Inshira Putri P 10-10-2021 N 15 H √ √ √ x x √ √ x x √
72 Nabila Yahya L 17-11-2020 N 14 H √ √ √ x x √ √ √ x √
73 M.Zafran Alydin L 10-12-2020 N 14 H √ √ √ x x √ √ √ x √
74 3317060901210004 Salman Usmani L 09-01-2021 N 12 H √ √ √ x x √ √ √ √ √
75 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 11 H √ √ √ x x √ √ √ x √
76 Humaira Rahma P 03-03-2021 N 9 H √ √ √ x x √ √ √ x √
77 Muhammad Kenzo Alvaro L 04-05-2021 N 7 H √ √ √ x x √ √ √ x √
78 Muhammad Faisal Hakim L 05-06-2021 N 7 H √ √ √ x x √ √ x x √
79 Muhammad Mazzin Mujtaba L 25-06-2021 N 6 H √ √ √ x x √ √ x x x
80 M. Hazin Musaddad L 15-07-2021 N 6 H √ √ √ x x √ √ x x x
81 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 5 H √ √ √ x x √ √ x x x
82 Nur Laila Atiya P 10-08-2021 N 5 H √ √ √ x x √ √ x x x
83 Abdul Alfa Rizqi L 05-08-2021 N 5 H √ √ √ x x √ √ x x x
84 Hibatul Maula P 13-11-2021 N 2 H √ √ √ x x √ √ x x x
85 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 2 H √ √ √ x x √ √ x √ x
86 Muhammad Najid Fayyad L 27-11-2021 N 1 H √ √ √ x x √ √ x x x
87 3317062202200002 Abdullah Azka L 22-02-2020 N 22 H √ √ √ √ x √ √ √ x √
88 Zidna Risqiya P 12-04-2020 N 21 H √ √ √ x x √ √ √ x √
89 Syarif Hidayatullah L 11-05-2020 N 20 H √ √ √ x x √ √ √ x √
90 Ahmad Sirojudin Aqil L 26-06-2020 N 18 H √ √ √ √ x √ √ √ x √
91 M.Mirzani Al-Afasi L 09-07-2020 N 17 H √ √ √ x x √ √ √ x √
92 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 12 H √ √ √ x x √ √ √ x √
93 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 12 K √ √ √ x √ √ √ √ x √
94 Karina Mazaya Dzakiyah P 23-12-2020 N 12 H √ √ √ x x √ √ √ x √
95 Danial Abdul Syakur Asif L 26-12-2020 N 12 H √ √ √ x x √ √ √ x √
96 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 8 H √ √ √ x x √ √ √ x √
97 3317062405210002 Azka Latiful Umam L 24-05-2021 N 7 H √ √ √ x x √ √ x x √
98 Asna Khusnin Nada P 25-06-2021 N 6 H √ √ √ x x √ √ √ x x
99 3317065909210002 Widdatul Ulya P 19-09-2021 N 4 H √ √ √ x x √ √ x x x

Sidorejo, 31 Januari 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 2
K 2 2
95
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : FEBRUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061402200001 Syafira Aida Zahra P 14-02-2020 S 23 M √ √ √ √ √ √ √ √ √ √
2 3317061403200001 Muhammad Alfan Amiqol Fahmi L 14-03-2020 N 23 H √ √ √ √ x √ √ √ x √
3 3317062203200001 Putri Khumaira Assifa P 22-03-2020 N 22 H √ √ √ √ x √ √ √ x √
4 3317061404200002 Zariatun Na'mah P 14-04-2020 N 21 H √ √ √ √ x √ √ √ x √
5 3317063004200002 Elva Aprilia Ramadhani P 30-04-2020 N 21 H √ √ √ √ x √ √ √ x √
6 Waji'atul Khusna P 03-07-2020 N 19 H √ √ √ √ x √ √ √ x √
7 Muhammad Ridho Rafian L 13-08-2020 N 18 H √ √ √ √ x √ √ √ x √
8 Nabila Asna P 25-08-2020 N 17 H √ √ √ √ x √ √ √ x √
9 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 17 H √ √ √ x x √ √ √ x √
10 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 16 H √ √ √ √ x √ √ √ x √
11 Azam Maulana Putra L 24-09-2020 N 16 H √ √ √ x x √ √ √ x √
12 Danis Ahmad Faisal L 25-09-2020 N 16 H √ √ √ x x √ √ √ x √
13 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 16 H √ √ √ x x √ √ √ x √
14 Asna Maulidya Putri P 29-11-2020 N 15 H √ √ √ x x √ √ √ x √
15 M.Ridwan Alfaris L 07-11-2020 N 15 H √ √ √ x x √ √ √ x √
16 3317060302210001 Muhammad Ubaidilah Majid L 03-12-2021 N 12 H √ √ √ x x √ √ √ x √
17 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 11 H √ √ √ √ x √ √ √ x √
18 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 11 H √ √ √ x x √ √ √ x √
19 Ahmad Farhan Alalifi L 23-02-2021 N 11 H √ √ √ x x √ √ √ x √
20 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 11 H √ √ √ x x √ √ √ x √
21 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 10 H √ √ √ x x √ √ √ x √
22 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 9 H √ √ √ x x √ √ √ x √
23 Yumna Ziyanada Kalisa P 28-04-2021 N 9 H √ √ √ x x √ √ x x √
24 M. Azmi Alfarizi L 18-05-2021 N 8 H √ √ √ x x √ √ x x √
25 Ahmad Mushollin L 19-06-2021 N 7 H √ √ √ √ x √ √ x x x
26 Maryam Eliza Khasanah P 27-06-2021 N 7 H √ √ √ √ x √ √ x x x
27 Niko Rafif Pratama L 19-07-2021 N 6 H √ √ √ √ x √ √ x x x
28 Laila Wasiatun Maghfiroh L 12-09-2021 N 5 H √ √ √ x x √ √ x x x
29 Muhammad Syadid L 13-09-2021 N 5 H √ √ √ x x √ √ x x x
30 Farel Ahmad Fatian L 18-09-2021 N 5 H √ √ √ x x √ √ x x x
31 Seva Tia Azzahra P 18-09-2021 N 5 H √ √ √ √ x √ √ x x x
32 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 4 H √ √ √ √ x √ √ x x x
33 3317062612190003 Muhammad Khizbun Naja P 26-12-2019 N 23 H √ √ √ √ x √ √ √ √ √
34 3317061402200000 Abdullah Syamikh L 14-02-2020 N 23 H √ √ √ √ x √ √ √ √ √
35 Ghibran Adidama Athalla L 31-05-2020 N 21 H √ √ √ √ x √ √ √ x √
36 Qiba Mufti L 13-07-2020 N 18 H √ √ √ x x √ √ √ x √
37 Asfa Azkiya Nahda P 19-12-2020 N 14 H √ √ √ x x √ √ √ x √
38 Zaidatul Khusna P 15-11-2020 N 14 H √ √ √ x x √ √ √ x √
39 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 12 H √ √ √ x x √ √ √ x √
40 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 10 H √ √ √ x x √ √ √ x √
41 Hilyatun Nisa P 20-10-2021 N 3 H √ √ √ x x √ √ x x x
42 3317060103200002 Khaizul Ma'ali L 01-03-2020 N 23 H √ √ √ √ x √ √ √ x √
43 3317060805200001 Jazilatun Na'mah P 08-05-2020 N 21 H √ √ √ √ x √ √ √ x √
44 3317060106200002 M.Busrol Karim L 01-06-2020 N 20 H √ √ √ √ x √ √ √ x √
45 3317060206200002 M.Reihan Kamil L 02-06-2020 N 20 H √ √ √ √ x √ √ √ x √
46 3317066206200001 Nihayatun Nikmah P 22-06-2020 N 20 H √ √ √ √ x √ √ √ x √
47 3317062910200001 M.Fatin Kamil L 29-10-2020 N 15 H √ √ √ x x √ √ √ x x
48 3317067008200002 Siti Zulfa Zahra P 30-08-2020 N 18 H √ √ √ √ x √ √ √ x √
49 3317062709200001 M.Miftahul Huda L 27-09-2020 N 18 H √ √ √ √ x √ √ √ x √
50 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 18 H √ √ √ √ x √ √ √ x √
51 3317062911200001 M.Chasan Jamil L 29-11-2020 N 14 H √ √ √ x x √ √ √ x √
52 Fatimah Yaqut Fahriyani P 08-01-2021 N 13 H √ √ √ x x √ √ √ x √
53 3317066001210001 Fina Saadah P 20-01-2021 N 12 H √ √ √ x x √ √ x x √
54 3317061402210002 M. Idror L 14-02-2021 N 12 H √ √ √ x x √ √ x x √
55 3317062007210002 M. Fahriza Akbar L 05-15-2021 N 9 H √ √ √ x x √ √ x x √
56 Alifia Nazla Nurul Ilmi P 30-05-2021 N 8 H √ √ √ x x √ √ x x √
57 Muh. Asyraf Tsaquf L 07-07-2021 N 7 H √ √ √ x x √ √ x x x
58 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 5 H √ √ √ x x √ √ x x x
59 3317061803200001 M.Rifqi Abidin L 18-03-2020 N 23 H √ √ √ √ x √ √ √ √ √
60 3317060904200001 Amelia Safira P 09-04-2020 N 22 H √ √ √ √ x √ √ √ √ √
61 3317062904200002 Ahmad Naja Ramadhani L 29-04-2020 N 21 H √ √ √ √ x √ √ √ √ √
62 3317063104200001 M.Arfan Romadhon L 31-04-2020 N 21 H √ √ √ √ x √ √ √ √ √
63 3317062605200001 M.Zaki Alfarizqi L 26-05-2020 S 20 M √ √ √ √ √ √ √ √ √ √
64 3317062705200001 Naura Azka Almira P 27-05-2020 N 20 H √ √ √ √ x √ √ √ √ √
65 A.Shofiul Asmi Alashari L 26-07-2020 N 18 H √ √ √ x x √ √ √ x √
66 Nabila Zafira Andini P 17-09-2020 N 17 H √ √ √ x x √ √ √ x √
67 Nayyila Inshira Putri P 10-10-2021 N 16 H √ √ √ x x √ √ x x √
68 Nabila Yahya L 17-11-2020 N 15 H √ √ √ x x √ √ √ x √
69 M.Zafran Alydin L 10-12-2020 N 15 H √ √ √ x x √ √ √ x √
70 3317060901210004 Salman Usmani L 09-01-2021 N 13 H √ √ √ x x √ √ √ √ √
71 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 12 H √ √ √ x x √ √ √ x √
72 Humaira Rahma P 03-03-2021 N 10 H √ √ √ x x √ √ √ x √
73 Muhammad Kenzo Alvaro L 04-05-2021 N 8 H √ √ √ x x √ √ √ x √
74 Muhammad Faisal Hakim L 05-06-2021 N 8 H √ √ √ x x √ √ x x √
75 Muhammad Mazzin Mujtaba L 25-06-2021 N 7 H √ √ √ x x √ √ x x x
76 M. Hazin Musaddad L 15-07-2021 N 7 H √ √ √ x x √ √ x x x
77 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 6 H √ √ √ x x √ √ x x x
78 Nur Laila Atiya P 10-08-2021 N 6 H √ √ √ x x √ √ x x x
79 Abdul Alfa Rizqi L 05-08-2021 N 6 H √ √ √ x x √ √ x x x
80 Hibatul Maula P 13-11-2021 N 3 H √ √ √ x x √ √ x x x
81 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 3 H √ √ √ x x √ √ x √ x
82 Muhammad Najid Fayyad L 27-11-2021 N 2 H √ √ √ x x √ √ x x x
83 3317062202200002 Abdullah Azka L 22-02-2020 N 23 H √ √ √ √ x √ √ √ x √
84 Zidna Risqiya P 12-04-2020 N 22 H √ √ √ x x √ √ √ x √
85 Syarif Hidayatullah L 11-05-2020 N 21 H √ √ √ x x √ √ √ x √
86 Ahmad Sirojudin Aqil L 26-06-2020 N 19 H √ √ √ √ x √ √ √ x √
87 M.Mirzani Al-Afasi L 09-07-2020 N 18 H √ √ √ x x √ √ √ x √
88 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 13 H √ √ √ x x √ √ √ x √
89 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 13 K √ √ √ x √ √ √ √ x √
90 Karina Mazaya Dzakiyah P 23-12-2020 N 13 H √ √ √ x x √ √ √ x √
91 Danial Abdul Syakur Asif L 26-12-2020 N 13 H √ √ √ x x √ √ √ x √
92 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 9 H √ √ √ x x √ √ √ x √
93 3317062405210002 Azka Latiful Umam L 24-05-2021 N 8 H √ √ √ x x √ √ x x √
94 Asna Khusnin Nada P 25-06-2021 N 7 H √ √ √ x x √ √ √ x x
95 3317065909210002 Widdatul Ulya P 19-09-2021 N 5 H √ √ √ x x √ √ x x x

Sidorejo, 28 Februari 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 2
K 1 1
92
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : MARET
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
3 3317062203200001 Putri Khumaira Assifa P 22-03-2020 N 23 H √ √ √ √ x √ √ √ x √
4 3317061404200002 Zariatun Na'mah P 14-04-2020 N 22 H √ √ √ √ x √ √ √ x √
5 3317063004200002 Elva Aprilia Ramadhani P 30-04-2020 N 22 H √ √ √ √ x √ √ √ x √
6 Waji'atul Khusna P 03-07-2020 N 20 H √ √ √ √ x √ √ √ x √
7 Muhammad Ridho Rafian L 13-08-2020 N 19 H √ √ √ √ x √ √ √ x √
8 Nabila Asna P 25-08-2020 N 18 H √ √ √ √ x √ √ √ x √
9 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 18 H √ √ √ x x √ √ √ x √
10 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 17 H √ √ √ √ x √ √ √ x √
11 Azam Maulana Putra L 24-09-2020 N 17 H √ √ √ x x √ √ √ x √
12 Danis Ahmad Faisal L 25-09-2020 N 17 H √ √ √ x x √ √ √ x √
13 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 17 H √ √ √ x x √ √ √ x √
14 Asna Maulidya Putri P 29-11-2020 N 16 H √ √ √ x x √ √ √ x √
15 M.Ridwan Alfaris L 07-11-2020 N 16 H √ √ √ x x √ √ √ x √
16 3317060302210001 Muhammad Ubaidilah Majid L 03-12-2021 N 13 H √ √ √ x x √ √ √ x √
17 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 12 H √ √ √ √ x √ √ √ x √
18 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 12 H √ √ √ x x √ √ √ x √
19 Ahmad Farhan Alalifi L 23-02-2021 N 12 H √ √ √ x x √ √ √ x √
20 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 12 H √ √ √ x x √ √ √ x √
21 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 11 H √ √ √ x x √ √ √ x √
22 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 10 H √ √ √ x x √ √ √ x √
23 Yumna Ziyanada Kalisa P 28-04-2021 N 10 H √ √ √ x x √ √ x x √
24 M. Azmi Alfarizi L 18-05-2021 N 9 H √ √ √ x x √ √ x x √
25 Ahmad Mushollin L 19-06-2021 N 8 H √ √ √ √ x √ √ x x √
26 Maryam Eliza Khasanah P 27-06-2021 N 8 H √ √ √ √ x √ √ x x √
27 Niko Rafif Pratama L 19-07-2021 N 7 H √ √ √ √ x √ √ x x √
28 Laila Wasiatun Maghfiroh L 12-09-2021 N 6 H √ √ √ x x √ √ x x √
29 Muhammad Syadid L 13-09-2021 N 6 H √ √ √ x x √ √ x x √
30 Farel Ahmad Fatian L 18-09-2021 N 6 H √ √ √ x x √ √ x x √
31 Seva Tia Azzahra P 18-09-2021 N 6 H √ √ √ √ x √ √ x x √
32 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 5 H √ √ √ √ x √ √ x x x
35 Ghibran Adidama Athalla L 31-05-2020 N 22 H √ √ √ √ x √ √ √ x √
36 Qiba Mufti L 13-07-2020 N 19 H √ √ √ x x √ √ √ x √
37 Asfa Azkiya Nahda P 19-12-2020 N 15 H √ √ √ x x √ √ √ x √
38 Zaidatul Khusna P 15-11-2020 N 15 H √ √ √ x x √ √ √ x √
39 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 13 H √ √ √ x x √ √ √ x √
40 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 11 H √ √ √ x x √ √ √ x √
41 Hilyatun Nisa P 20-10-2021 N 4 H √ √ √ x x √ √ x x x
43 3317060805200001 Jazilatun Na'mah P 08-05-2020 N 22 H √ √ √ √ x √ √ √ x √
44 3317060106200002 M.Busrol Karim L 01-06-2020 N 21 H √ √ √ √ x √ √ √ x √
45 3317060206200002 M.Reihan Kamil L 02-06-2020 N 21 H √ √ √ √ x √ √ √ x √
46 3317066206200001 Nihayatun Nikmah P 22-06-2020 N 21 H √ √ √ √ x √ √ √ x √
47 3317062910200001 M.Fatin Kamil L 29-10-2020 N 16 H √ √ √ x x √ √ √ x x
48 3317067008200002 Siti Zulfa Zahra P 30-08-2020 N 19 H √ √ √ √ x √ √ √ x √
49 3317062709200001 M.Miftahul Huda L 27-09-2020 N 19 H √ √ √ √ x √ √ √ x √
50 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 19 H √ √ √ √ x √ √ √ x √
51 3317062911200001 M.Chasan Jamil L 29-11-2020 N 15 H √ √ √ x x √ √ √ x √
52 Fatimah Yaqut Fahriyani P 08-01-2021 N 14 H √ √ √ x x √ √ √ x √
53 3317066001210001 Fina Saadah P 20-01-2021 N 13 H √ √ √ x x √ √ x x √
54 3317061402210002 M. Idror L 14-02-2021 N 13 H √ √ √ x x √ √ x x √
55 3317062007210002 M. Fahriza Akbar L 05-15-2021 N 10 H √ √ √ x x √ √ x x √
56 Alifia Nazla Nurul Ilmi P 30-05-2021 N 9 H √ √ √ x x √ √ x x √
57 Muh. Asyraf Tsaquf L 07-07-2021 N 8 H √ √ √ x x √ √ x x √
58 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 6 H √ √ √ x x √ √ x x √
60 3317060904200001 Amelia Safira P 09-04-2020 N 23 H √ √ √ √ x √ √ √ √ √
61 3317062904200002 Ahmad Naja Ramadhani L 29-04-2020 N 22 H √ √ √ √ x √ √ √ √ √
62 3317063104200001 M.Arfan Romadhon L 31-04-2020 N 22 H √ √ √ √ x √ √ √ √ √
63 3317062605200001 M.Zaki Alfarizqi L 26-05-2020 S 21 M √ √ √ √ √ √ √ √ √ √
64 3317062705200001 Naura Azka Almira P 27-05-2020 N 21 H √ √ √ √ x √ √ √ √ √
65 A.Shofiul Asmi Alashari L 26-07-2020 N 19 H √ √ √ x x √ √ √ x √
66 Nabila Zafira Andini P 17-09-2020 N 18 H √ √ √ x x √ √ √ x √
67 Nayyila Inshira Putri P 10-10-2021 N 17 H √ √ √ x x √ √ x x √
68 Nabila Yahya L 17-11-2020 N 16 H √ √ √ x x √ √ √ x √
69 M.Zafran Alydin L 10-12-2020 N 16 H √ √ √ x x √ √ √ x √
70 3317060901210004 Salman Usmani L 09-01-2021 N 14 H √ √ √ x x √ √ √ √ √
71 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 13 H √ √ √ x x √ √ √ x √
72 Humaira Rahma P 03-03-2021 N 11 H √ √ √ x x √ √ √ x √
73 Muhammad Kenzo Alvaro L 04-05-2021 N 9 H √ √ √ x x √ √ √ x √
74 Muhammad Faisal Hakim L 05-06-2021 N 9 H √ √ √ x x √ √ x x √
75 Muhammad Mazzin Mujtaba L 25-06-2021 N 8 H √ √ √ x x √ √ x x √
76 M. Hazin Musaddad L 15-07-2021 N 8 H √ √ √ x x √ √ x x √
77 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 7 H √ √ √ x x √ √ x x √
78 Nur Laila Atiya P 10-08-2021 N 7 H √ √ √ x x √ √ x x √
79 Abdul Alfa Rizqi L 05-08-2021 N 7 H √ √ √ x x √ √ x x √
80 Hibatul Maula P 13-11-2021 N 4 H √ √ √ x x √ √ x x x
81 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 4 H √ √ √ x x √ √ x √ x
82 Muhammad Najid Fayyad L 27-11-2021 N 3 H √ √ √ x x √ √ x x x
84 Zidna Risqiya P 12-04-2020 N 23 H √ √ √ x x √ √ √ x √
85 Syarif Hidayatullah L 11-05-2020 N 22 H √ √ √ x x √ √ √ x √
86 Ahmad Sirojudin Aqil L 26-06-2020 N 20 H √ √ √ √ x √ √ √ x √
87 M.Mirzani Al-Afasi L 09-07-2020 N 19 H √ √ √ x x √ √ √ x √
88 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 14 H √ √ √ x x √ √ √ x √
89 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 14 K √ √ √ x √ √ √ √ x √
90 Karina Mazaya Dzakiyah P 23-12-2020 N 14 H √ √ √ x x √ √ √ x √
91 Danial Abdul Syakur Asif L 26-12-2020 N 14 H √ √ √ x x √ √ √ x √
92 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 10 H √ √ √ x x √ √ √ x √
93 3317062405210002 Azka Latiful Umam L 24-05-2021 N 9 H √ √ √ x x √ √ x x √
94 Asna Khusnin Nada P 25-06-2021 N 8 H √ √ √ x x √ √ √ x √
95 3317065909210002 Widdatul Ulya P 19-09-2021 N 6 H √ √ √ x x √ √ x x √
 Sidorejo, 31 Maret 2022
KPM DESA SIDOREJO

Nailis Saadah

B 0 1
S 1
K 1 1
86
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : APRIL
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061404200002 Zariatun Na'mah P 14-04-2020 N 23 H √ √ √ √ x √ √ √ x √
2 3317063004200002 Elva Aprilia Ramadhani P 30-04-2020 N 23 H √ √ √ √ x √ √ √ x √
3 Waji'atul Khusna P 03-07-2020 N 21 H √ √ √ √ x √ √ √ x √
4 Muhammad Ridho Rafian L 13-08-2020 N 20 H √ √ √ √ x √ √ √ x √
5 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 18 H √ √ √ √ x √ √ √ x √
6 Nabila Asna P 25-08-2020 N 19 H √ √ √ √ x √ √ √ x √
7 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 19 H √ √ √ x x √ √ √ x √
8 Azam Maulana Putra L 24-09-2020 N 18 H √ √ √ x x √ √ √ x √
9 Danis Ahmad Faisal L 25-09-2020 N 18 H √ √ √ x x √ √ √ x √
10 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 18 H √ √ √ x x √ √ √ x √
11 M.Ridwan Alfaris L 07-11-2020 N 17 H √ √ √ x x √ √ √ x √
12 Asna Maulidya Putri P 29-11-2020 N 17 H √ √ √ x x √ √ √ x √
13 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 14 H √ √ √ x x √ √ √ x √
14 Ahmad Farhan Alalifi L 23-02-2021 N 13 H √ √ √ x x √ √ √ x √
15 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 13 H √ √ √ x x √ √ √ x √
16 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 13 H √ √ √ √ x √ √ √ x √
17 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 13 H √ √ √ x x √ √ √ x √
18 Farha Nisyatul Mazaya P 05-03-2021 N 13 H √ √ √ √ x √ √ √ x √
19 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 12 H √ √ √ x x √ √ √ x √
20 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 11 H √ √ √ x x √ √ √ x √
21 Yumna Ziyanada Kalisa P 28-04-2021 N 11 H √ √ √ x x √ √ √ x √
22 M. Azmi Alfarizi L 18-05-2021 N 10 H √ √ √ x x √ √ √ x √
23 Ahmad Mushollin L 19-06-2021 N 9 H √ √ √ √ x √ √ √ x √
24 Maryam Eliza Khasanah P 27-06-2021 N 9 H √ √ √ √ x √ √ √ x √
25 Niko Rafif Pratama L 19-07-2021 N 8 H √ √ √ √ x √ √ √ x √
26 Ahmad Diyaunnas L 06-08-2021 N 8 H √ √ √ √ x √ √ √ x √
27 Muhammad Rosikhul Ulum L 07-08-2021 N 8 H √ √ √ x x √ √ √ x √
28 Laila Wasiatun Maghfiroh L 12-09-2021 N 7 H √ √ √ x x √ √ √ x √
29 Muhammad Syadid L 13-09-2021 K 7 K √ √ √ √ √ √ √ √ x √
30 Farel Ahmad Fatian L 18-09-2021 N 7 H √ √ √ x x √ √ √ x √
31 Seva Tia Azzahra P 18-09-2021 N 7 H √ √ √ √ x √ √ √ x √
32 Muhammad Muhtar Alhaq L 01-10-2021 N 6 H √ √ √ x x √ √ x x √
33 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 6 H √ √ √ √ x √ √ x x √
34 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 5 H √ √ √ √ x √ √ x x x
35 Adiba Zahrotut Tazkiyah P 09-11-2021 N 5 H √ √ √ x x √ √ x x x
36 M. Dias Arsyad L 09-11-2021 N 5 H √ √ √ √ x √ √ x x x
37 Muhammad Fathan Alvaro L 04-12-2021 K 4 K √ √ √ √ √ √ √ x x x
38 Kenzu Febrian Alfarizqi L 13-02-2022 N 2 H √ √ √ √ x √ √ x x x
39 Raisa Malinda Ramadhani P 02-04-2022 N 0 H √ √ √ √ x √ √ x x x
40 Athiqoh Fadhilah P 02-04-2022 N 0 H √ √ √ √ x √ √ x x x
41 Ghibran Adidama Athalla L 31-05-2020 N 23 H √ √ √ √ x √ √ √ x √
42 Qiba Mufti L 13-07-2020 N 20 H √ √ √ x x √ √ √ x √
43 Asfa Azkiya Nahda P 19-12-2020 N 16 H √ √ √ x x √ √ √ x √
44 Zaidatul Khusna P 15-11-2020 N 16 H √ √ √ x x √ √ √ x √
45 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 14 H √ √ √ x x √ √ √ x √
46 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 12 H √ √ √ x x √ √ √ x √
47 Qiyana Zahra Athiqoh P 07-05-2021 K 10 K √ √ √ √ √ √ √ √ x √
48 Hilyatun Nisa P 20-10-2021 K 5 M √ √ √ √ √ √ √ √ x x
49 Aisyah Humaira P 20-10-2021 N 5 H √ √ √ √ x √ √ x x x
50 Thifa Ulya P 21-12-2021 N 4 H √ √ √ √ x √ √ x x x
51 Fabian Azmi L 30-12-2021 N 4 H √ √ √ √ x √ √ x x x
52 Syauqi Ramadhan L 06-04-2022 N 0 H √ √ √ √ x √ √ x x x
53 3317060805200001 Jazilatun Na'mah P 08-05-2020 N 23 H √ √ √ √ x √ √ √ x √
54 3317060106200002 M.Busrol Karim L 01-06-2020 N 22 H √ √ √ √ x √ √ √ x √
55 3317060206200002 M.Reihan Kamil L 02-06-2020 N 22 H √ √ √ √ x √ √ √ x √
56 3317066206200001 Nihayatun Nikmah P 22-06-2020 N 22 H √ √ √ √ x √ √ √ x √
57 3317062709200001 M.Miftahul Huda L 27-09-2020 N 20 H √ √ √ √ x √ √ √ x √
58 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 20 H √ √ √ √ x √ √ √ x √
59 3317062910200001 M.Fatin Kamil L 29-10-2020 N 17 H √ √ √ x x √ √ √ x √
60 Aina Mardiyah P 05-11-2020 K 16 K √ √ √ √ √ √ √ √ x
61 M. Zidni Huda L 06-11-2020 N 16 H √ √ √ x x √ √ √ x √
62 3317062911200001 M.Chasan Jamil L 29-11-2020 N 16 H √ √ √ x x √ √ √ x √
63 Fatimah Yaqut Fahriyani P 08-01-2021 N 15 H √ √ √ x x √ √ √ x √
64 3317066001210001 Fina Saadah P 20-01-2021 N 14 H √ √ √ x x √ √ √ x √
65 3317061402210002 M. Idror L 14-02-2021 N 14 H √ √ √ x x √ √ √ x √
66 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 11 H √ √ √ x x √ √ √ x √
67 Aisyah Najla Rosyidah P 15-05-2021 N 11 H √ √ √ x x √ √ √ x √
68 Alifia Nazla Nurul Ilmi P 30-05-2021 N 10 H √ √ √ x x √ √ √ x √
69 Adzkiya Noura Umar P 06-07-2021 N 9 H √ √ √ x x √ √ √ x √
70 Muh. Asyraf Tsaquf L 07-07-2021 N 9 H √ √ √ x x √ √ √ x √
71 Dina Putri Aulia P 23-07-2021 N 9 H √ √ √ x x √ √ √ x √
72 Sanum Azzarein P 10-08-2021 N 8 H √ √ √ √ x √ √ √ x √
73 Afika Lidya Putri P 28-08-2021 N 8 H √ √ √ x x √ √ √ x √
74 Fatimah Rayla Zara P 31-08-2021 N 8 H √ √ √ x x √ √ √ x √
75 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 7 H √ √ √ x x √ √ √ x √
76 M. Ardiansyah L 02-10-2021 N 6 H √ √ √ √ x √ √ √ x √
77 M. Iqbal L 31-10-2021 N 6 H √ √ √ √ x √ √ x x √
78 Adzkiy Dinillah L 18-12-2021 N 4 H √ √ √ √ x √ √ x x x
79 Nayyira Zuyyina Salsabila P 21-12-2021 N 4 H √ √ √ √ x √ √ x x x
80 M. Ali Imron L 22-01-2022 N 3 H √ √ √ √ x √ √ x x x
81 M. Salman Farisi L 09-03-2022 N 1 H √ √ √ √ x √ √ x x x
82 Zaqiyatun Nisa P 09-03-2022 N 1 H √ √ √ √ x √ √ x x x
83 3317062904200002 Ahmad Naja Ramadhani L 29-04-2020 N 23 H √ √ √ √ x √ √ √ √ √
84 3317063104200001 M.Arfan Romadhon L 31-04-2020 N 23 H √ √ √ √ x √ √ √ √ √
85 3317062605200001 M.Zaki Alfarizqi L 26-05-2020 S 22 M √ √ √ √ √ √ √ √ √ √
86 3317062705200001 Naura Azka Almira P 27-05-2020 N 22 H √ √ √ √ x √ √ √ √ √
87 A.Shofiul Asmi Alashari L 26-07-2020 K 20 K √ √ √ √ √ √ √ √ x √
88 Nabila Zafira Andini P 17-09-2020 N 19 H √ √ √ x x √ √ √ x √
 89 Nayyila Inshira Putri P 10-10-2021 N 18 H √ √ √ x x √ √ x x √
90 Nabila Yahya L 17-11-2020 N 17 H √ √ √ x x √ √ √ x √
91 M.Zafran Alydin L 10-12-2020 N 17 H √ √ √ x x √ √ √ x √
92 3317060901210004 Salman Usmani L 09-01-2021 N 15 H √ √ √ x x √ √ √ √ √
93 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 14 H √ √ √ x x √ √ √ x √
94 Humaira Rahma P 03-03-2021 N 12 H √ √ √ x x √ √ √ x √
95 Usman Faqih Abdillah L 25-03-2021 N 12 H √ √ √ x x √ √ x x √
96 Muhammad Kenzo Alvaro L 04-05-2021 N 10 H √ √ √ x x √ √ √ x √
97 Muhammad Faisal Hakim L 05-06-2021 K 10 K √ √ √ √ √ √ √ √ x √
98 Muhammad Mazzin Mujtaba L 25-06-2021 N 9 H √ √ √ x x √ √ √ x √
99 M. Hazin Musaddad L 15-07-2021 N 9 H √ √ √ x x √ √ √ x √
100 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 8 H √ √ √ x x √ √ √ x √
101 Nur Laila Atiya P 10-08-2021 K 8 K √ √ √ √ √ √ √ x x √
102 Hibatul Maula P 13-11-2021 N 5 H √ √ √ x x √ √ x x x
103 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 5 H √ √ √ x x √ √ x √ x
104 Muhammad Najid Fayyad L 27-11-2021 N 4 H √ √ √ x x √ √ x x x
105 Ahnaf Nufayyi' L 04-01-2022 N 3 H √ √ √ √ x √ √ x x x
106 Naswa Yumna Ramadhani P 22-04-2022 N 0 H √ √ √ √ x √ √ x x x
107 Syarif Hidayatullah L 11-05-2020 N 23 H √ √ √ x x √ √ √ x √
108 Ahmad Sirojudin Aqil L 26-06-2020 N 21 H √ √ √ √ x √ √ √ x √
109 M.Mirzani Al-Afasi L 09-07-2020 N 20 H √ √ √ x x √ √ √ x √
110 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 15 H √ √ √ x x √ √ √ x √
111 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 15 M √ √ √ √ √ √ √ √ x √
112 Karina Mazaya Dzakiyah P 23-12-2020 N 15 H √ √ √ x x √ √ √ x √
113 Danial Abdul Syakur Asif L 26-12-2020 N 15 H √ √ √ x x √ √ √ x √
114 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 11 H √ √ √ x x √ √ √ x √
115 3317062405210002 Azka Latiful Umam L 24-05-2021 N 10 H √ √ √ √ x √ √ √ x √
116 Asna Khusnin Nada P 25-06-2021 N 9 H √ √ √ √ x √ √ √ x √
117 3317065909210002 Widdatul Ulya P 19-09-2021 N 7 H √ √ √ √ x √ √ √ x √
118 BY. Nurul Maunah L 13-02-2022 N 2 H √ √ √ x x √ √ x x x
119 Umi Habibah P 25-03-2022 N 1 H √ √ √ x x √ √ x x x

Sidorejo, 30 April 2022

KPM DESA SIDOREJO
 Nailis Saadah

B 0 3
S 1
K 9 7
109
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : MEI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Waji'atul Khusna P 03-07-2020 N 22 H √ √ √ √ x √ √ √ x √
2 Muhammad Ridho Rafian L 13-08-2020 N 21 H √ √ √ √ x √ √ √ x √
3 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 20 H √ √ √ √ x √ √ √ x √
4 Nabila Asna P 25-08-2020 N 20 H √ √ √ √ x √ √ √ x √
5 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 20 H √ √ √ x x √ √ √ x √
6 Azam Maulana Putra L 24-09-2020 N 19 H √ √ √ x x √ √ √ x √
7 Danis Ahmad Faisal L 25-09-2020 N 19 H √ √ √ x x √ √ √ x √
8 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 19 H √ √ √ x x √ √ √ x √
9 M.Ridwan Alfaris L 07-11-2020 N 18 H √ √ √ x x √ √ √ x √
10 Asna Maulidya Putri P 29-11-2020 N 18 H √ √ √ x x √ √ √ x √
11 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 15 H √ √ √ x x √ √ √ x √
12 Ahmad Farhan Alalifi L 23-02-2021 N 14 H √ √ √ x x √ √ √ x √
13 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 14 H √ √ √ x x √ √ √ x √
14 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 14 H √ √ √ √ x √ √ √ x √
15 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 14 H √ √ √ x x √ √ √ x √
16 Farha Nisyatul Mazaya P 05-03-2021 N 14 H √ √ √ √ x √ √ √ x √
17 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 13 H √ √ √ x x √ √ √ x √
18 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 12 H √ √ √ x x √ √ √ x √
19 Yumna Ziyanada Kalisa P 28-04-2021 N 12 H √ √ √ x x √ √ √ x √
20 M. Azmi Alfarizi L 18-05-2021 N 11 H √ √ √ x x √ √ √ x √
21 Ahmad Mushollin L 19-06-2021 N 10 H √ √ √ √ x √ √ √ x √
22 Maryam Eliza Khasanah P 27-06-2021 N 10 H √ √ √ √ x √ √ √ x √
23 Niko Rafif Pratama L 19-07-2021 N 9 H √ √ √ √ x √ √ √ x √
24 Ahmad Diyaunnas L 06-08-2021 N 9 H √ √ √ √ x √ √ √ x √
25 Muhammad Rosikhul Ulum L 07-08-2021 N 9 H √ √ √ x x √ √ √ x √
26 Laila Wasiatun Maghfiroh L 12-09-2021 N 8 H √ √ √ x x √ √ √ x √
27 Muhammad Syadid L 13-09-2021 K 8 K √ √ √ √ √ √ √ √ x √
28 Farel Ahmad Fatian L 18-09-2021 N 8 H √ √ √ x x √ √ √ x √
29 Seva Tia Azzahra P 18-09-2021 N 8 H √ √ √ √ x √ √ √ x √
30 Muhammad Muhtar Alhaq L 01-10-2021 N 7 H √ √ √ x x √ √ x x √
31 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 7 H √ √ √ √ x √ √ x x √
32 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 6 H √ √ √ √ x √ √ x x √
33 Adiba Zahrotut Tazkiyah P 09-11-2021 N 6 H √ √ √ x x √ √ x x √
34 M. Dias Arsyad L 09-11-2021 N 6 H √ √ √ √ x √ √ x x √
35 Muhammad Fathan Alvaro L 04-12-2021 K 5 K √ √ √ √ √ √ √ x x x
36 Kenzu Febrian Alfarizqi L 13-02-2022 N 3 H √ √ √ √ x √ √ x x x
37 Raisa Malinda Ramadhani P 02-04-2022 N 1 H √ √ √ √ x √ √ x x x
38 Athiqoh Fadhilah P 02-04-2022 N 1 H √ √ √ √ x √ √ x x x
39 Qiba Mufti L 13-07-2020 N 22 H √ √ √ x x √ √ √ x √
40 Asfa Azkiya Nahda P 19-12-2020 N 17 H √ √ √ x x √ √ √ x √
41 Zaidatul Khusna P 15-11-2020 N 17 H √ √ √ x x √ √ √ x √
42 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 15 H √ √ √ x x √ √ √ x √
43 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 13 H √ √ √ x x √ √ √ x √
44 Qiyana Zahra Athiqoh P 07-05-2021 K 11 K √ √ √ √ √ √ √ √ x √
45 Hilyatun Nisa P 20-10-2021 K 6 M √ √ √ √ √ √ √ √ x √
46 Aisyah Humaira P 20-10-2021 N 6 H √ √ √ √ x √ √ x x √
47 Thifa Ulya P 21-12-2021 N 5 H √ √ √ √ x √ √ x x x
48 Fabian Azmi L 30-12-2021 N 5 H √ √ √ √ x √ √ x x x
49 Syauqi Ramadhan L 06-04-2022 N 1 H √ √ √ √ x √ √ x x x
50 3317060106200002 M.Busrol Karim L 01-06-2020 N 23 H √ √ √ √ x √ √ √ x √
51 3317060206200002 M.Reihan Kamil L 02-06-2020 N 23 H √ √ √ √ x √ √ √ x √
52 3317066206200001 Nihayatun Nikmah P 22-06-2020 N 23 H √ √ √ √ x √ √ √ x √
53 3317062709200001 M.Miftahul Huda L 27-09-2020 N 21 H √ √ √ √ x √ √ √ x √
54 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 21 H √ √ √ √ x √ √ √ x √
55 3317062910200001 M.Fatin Kamil L 29-10-2020 N 18 H √ √ √ x x √ √ √ x √
56 Aina Mardiyah P 05-11-2020 K 17 K √ √ √ √ √ √ √ √ x
57 M. Zidni Huda L 06-11-2020 N 17 H √ √ √ x x √ √ √ x √
58 3317062911200001 M.Chasan Jamil L 29-11-2020 N 17 H √ √ √ x x √ √ √ x √
59 Fatimah Yaqut Fahriyani P 08-01-2021 N 16 H √ √ √ x x √ √ √ x √
60 3317066001210001 Fina Saadah P 20-01-2021 N 15 H √ √ √ x x √ √ √ x √
61 3317061402210002 M. Idror L 14-02-2021 N 15 H √ √ √ x x √ √ √ x √
62 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 12 H √ √ √ x x √ √ √ x √
63 Aisyah Najla Rosyidah P 15-05-2021 N 12 H √ √ √ x x √ √ √ x √
64 Alifia Nazla Nurul Ilmi P 30-05-2021 N 11 H √ √ √ x x √ √ √ x √
65 Adzkiya Noura Umar P 06-07-2021 N 10 H √ √ √ x x √ √ √ x √
66 Muh. Asyraf Tsaquf L 07-07-2021 N 10 H √ √ √ x x √ √ √ x √
67 Dina Putri Aulia P 23-07-2021 N 10 H √ √ √ x x √ √ √ x √
68 Sanum Azzarein P 10-08-2021 N 9 H √ √ √ √ x √ √ √ x √
69 Afika Lidya Putri P 28-08-2021 N 9 H √ √ √ x x √ √ √ x √
70 Fatimah Rayla Zara P 31-08-2021 N 9 H √ √ √ x x √ √ √ x √
71 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 8 H √ √ √ x x √ √ √ x √
72 M. Ardiansyah L 02-10-2021 N 7 H √ √ √ √ x √ √ √ x √
73 M. Iqbal L 31-10-2021 N 7 H √ √ √ √ x √ √ x x √
74 Adzkiy Dinillah L 18-12-2021 N 5 H √ √ √ √ x √ √ x x x
75 Nayyira Zuyyina Salsabila P 21-12-2021 N 5 H √ √ √ √ x √ √ x x x
76 M. Ali Imron L 22-01-2022 N 4 H √ √ √ √ x √ √ x x x
77 M. Salman Farisi L 09-03-2022 N 2 H √ √ √ √ x √ √ x x x
78 Zaqiyatun Nisa P 09-03-2022 N 2 H √ √ √ √ x √ √ x x x
79 3317062605200001 M.Zaki Alfarizqi L 26-05-2020 S 23 M √ √ √ √ √ √ √ √ √ √
80 3317062705200001 Naura Azka Almira P 27-05-2020 N 23 H √ √ √ √ x √ √ √ √ √
81 A.Shofiul Asmi Alashari L 26-07-2020 K 21 K √ √ √ √ √ √ √ √ x √
82 Nabila Zafira Andini P 17-09-2020 N 20 H √ √ √ x x √ √ √ x √
83 Nayyila Inshira Putri P 10-10-2021 N 19 H √ √ √ x x √ √ x x √
84 Nabila Yahya L 17-11-2020 N 18 H √ √ √ x x √ √ √ x √
85 M.Zafran Alydin L 10-12-2020 N 18 H √ √ √ x x √ √ √ x √
86 3317060901210004 Salman Usmani L 09-01-2021 N 16 H √ √ √ x x √ √ √ √ √
87 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 15 H √ √ √ x x √ √ √ x √
88 Humaira Rahma P 03-03-2021 N 13 H √ √ √ x x √ √ √ x √
 89 Usman Faqih Abdillah L 25-03-2021 N 13 H √ √ √ x x √ √ x x √
90 Muhammad Kenzo Alvaro L 04-05-2021 N 11 H √ √ √ x x √ √ √ x √
91 Muhammad Faisal Hakim L 05-06-2021 K 11 K √ √ √ √ √ √ √ √ x √
92 Muhammad Mazzin Mujtaba L 25-06-2021 N 10 H √ √ √ x x √ √ √ x √
93 M. Hazin Musaddad L 15-07-2021 N 10 H √ √ √ x x √ √ √ x √
94 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 9 H √ √ √ x x √ √ √ x √
95 Nur Laila Atiya P 10-08-2021 K 9 K √ √ √ √ √ √ √ x x √
96 Hibatul Maula P 13-11-2021 N 6 H √ √ √ x x √ √ x x √
97 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 6 H √ √ √ x x √ √ x √ √
98 Muhammad Najid Fayyad L 27-11-2021 N 5 H √ √ √ x x √ √ x x x
99 Ahnaf Nufayyi' L 04-01-2022 N 4 H √ √ √ √ x √ √ x x x
100 Naswa Yumna Ramadhani P 22-04-2022 N 1 H √ √ √ √ x √ √ x x x
101 Ahmad Sirojudin Aqil L 26-06-2020 N 22 H √ √ √ √ x √ √ √ x √
102 M.Mirzani Al-Afasi L 09-07-2020 N 21 H √ √ √ x x √ √ √ x √
103 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 16 H √ √ √ x x √ √ √ x √
104 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 16 M √ √ √ √ √ √ √ √ x √
105 Karina Mazaya Dzakiyah P 23-12-2020 N 16 H √ √ √ x x √ √ √ x √
106 Danial Abdul Syakur Asif L 26-12-2020 N 16 H √ √ √ x x √ √ √ x √
107 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 12 H √ √ √ x x √ √ √ x √
108 3317062405210002 Azka Latiful Umam L 24-05-2021 N 12 H √ √ √ √ x √ √ √ x √
109 Asna Khusnin Nada P 25-06-2021 N 10 H √ √ √ √ x √ √ √ x √
110 3317065909210002 Widdatul Ulya P 19-09-2021 N 8 H √ √ √ √ x √ √ √ x √
111 BY. Nurul Maunah L 13-02-2022 N 3 H √ √ √ x x √ √ x x x
112 Umi Habibah P 25-03-2022 N 2 H √ √ √ x x √ √ x x x

Sidorejo, 31 Mei 2022

KPM DESA SIDOREJO

Nailis Saadah
B 0 3
S 1
K 9 7
102
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : JUNI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Waji'atul Khusna P 03-07-2020 N 23 H √ √ √ √ x √ √ √ x √
2 Muhammad Ridho Rafian L 13-08-2020 N 22 H √ √ √ √ x √ √ √ x √
3 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 21 H √ √ √ √ x √ √ √ x √
4 Nabila Asna P 25-08-2020 N 21 H √ √ √ √ x √ √ √ x √
5 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 21 H √ √ √ x x √ √ √ x √
6 Azam Maulana Putra L 24-09-2020 N 20 H √ √ √ x x √ √ √ x √
7 Danis Ahmad Faisal L 25-09-2020 N 20 H √ √ √ x x √ √ √ x √
8 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 20 H √ √ √ x x √ √ √ x √
9 M.Ridwan Alfaris L 07-11-2020 N 19 H √ √ √ x x √ √ √ x √
10 Asna Maulidya Putri P 29-11-2020 N 19 H √ √ √ x x √ √ √ x √
11 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 16 H √ √ √ x x √ √ √ x √
12 Ahmad Farhan Alalifi L 23-02-2021 N 15 H √ √ √ x x √ √ √ x √
13 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 15 H √ √ √ x x √ √ √ x √
14 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 15 H √ √ √ √ x √ √ √ x √
15 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 15 H √ √ √ x x √ √ √ x √
16 Farha Nisyatul Mazaya P 05-03-2021 N 15 H √ √ √ √ x √ √ √ x √
17 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 14 H √ √ √ x x √ √ √ x √
18 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 13 H √ √ √ x x √ √ √ x √
19 Yumna Ziyanada Kalisa P 28-04-2021 N 13 H √ √ √ x x √ √ √ x √
20 M. Azmi Alfarizi L 18-05-2021 N 12 H √ √ √ x x √ √ √ x √
21 Ahmad Mushollin L 19-06-2021 N 11 H √ √ √ √ x √ √ √ x √
22 Maryam Eliza Khasanah P 27-06-2021 N 11 H √ √ √ √ x √ √ √ x √
23 Niko Rafif Pratama L 19-07-2021 N 10 H √ √ √ √ x √ √ √ x √
24 Ahmad Diyaunnas L 06-08-2021 N 10 H √ √ √ √ x √ √ √ x √
25 Muhammad Rosikhul Ulum L 07-08-2021 N 10 H √ √ √ x x √ √ √ x √
26 Laila Wasiatun Maghfiroh L 12-09-2021 N 9 H √ √ √ x x √ √ √ x √
27 Muhammad Syadid L 13-09-2021 K 9 K √ √ √ √ √ √ √ √ x √
28 Farel Ahmad Fatian L 18-09-2021 N 9 H √ √ √ x x √ √ √ x √
29 Seva Tia Azzahra P 18-09-2021 N 9 H √ √ √ √ x √ √ √ x √
30 Muhammad Muhtar Alhaq L 01-10-2021 N 8 H √ √ √ x x √ √ x x √
31 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 8 H √ √ √ √ x √ √ x x √
32 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 7 H √ √ √ √ x √ √ x x √
33 Adiba Zahrotut Tazkiyah P 09-11-2021 N 7 H √ √ √ x x √ √ x x √
34 M. Dias Arsyad L 09-11-2021 N 7 H √ √ √ √ x √ √ x x √
35 Muhammad Fathan Alvaro L 04-12-2021 K 6 K √ √ √ √ √ √ √ x x √
36 Kenzu Febrian Alfarizqi L 13-02-2022 N 4 H √ √ √ √ x √ √ x x x
37 Raisa Malinda Ramadhani P 02-04-2022 N 2 H √ √ √ √ x √ √ x x x
38 Athiqoh Fadhilah P 02-04-2022 N 2 H √ √ √ √ x √ √ x x x
39 Qiba Mufti L 13-07-2020 N 23 H √ √ √ x x √ √ √ x √
40 Asfa Azkiya Nahda P 19-12-2020 N 18 H √ √ √ x x √ √ √ x √
41 Zaidatul Khusna P 15-11-2020 N 18 H √ √ √ x x √ √ √ x √
42 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 16 H √ √ √ x x √ √ √ x √
43 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 14 H √ √ √ x x √ √ √ x √
44 Qiyana Zahra Athiqoh P 07-05-2021 K 12 K √ √ √ √ √ √ √ √ x √
45 Hilyatun Nisa P 20-10-2021 K 7 M √ √ √ √ √ √ √ √ x √
46 Aisyah Humaira P 20-10-2021 N 7 H √ √ √ √ x √ √ x x √
47 Thifa Ulya P 21-12-2021 N 6 H √ √ √ √ x √ √ x x √
48 Fabian Azmi L 30-12-2021 N 6 H √ √ √ √ x √ √ x x √
49 Syauqi Ramadhan L 06-04-2022 N 2 H √ √ √ √ x √ √ x x x
50 3317062709200001 M.Miftahul Huda L 27-09-2020 N 22 H √ √ √ √ x √ √ √ x √
51 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 22 H √ √ √ √ x √ √ √ x √
52 3317062910200001 M.Fatin Kamil L 29-10-2020 N 19 H √ √ √ x x √ √ √ x √
53 Aina Mardiyah P 05-11-2020 K 18 K √ √ √ √ √ √ √ √ x √
54 M. Zidni Huda L 06-11-2020 N 18 H √ √ √ x x √ √ √ x √
55 3317062911200001 M.Chasan Jamil L 29-11-2020 N 18 H √ √ √ x x √ √ √ x √
56 Fatimah Yaqut Fahriyani P 08-01-2021 N 17 H √ √ √ x x √ √ √ x √
57 3317066001210001 Fina Saadah P 20-01-2021 N 16 H √ √ √ x x √ √ √ x √
58 3317061402210002 M. Idror L 14-02-2021 N 16 H √ √ √ x x √ √ √ x √
59 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 13 H √ √ √ x x √ √ √ x √
60 Aisyah Najla Rosyidah P 15-05-2021 N 13 H √ √ √ x x √ √ √ x √
61 Alifia Nazla Nurul Ilmi P 30-05-2021 N 12 H √ √ √ x x √ √ √ x √
62 Adzkiya Noura Umar P 06-07-2021 N 11 H √ √ √ x x √ √ √ x √
63 Muh. Asyraf Tsaquf L 07-07-2021 N 11 H √ √ √ x x √ √ √ x √
64 Dina Putri Aulia P 23-07-2021 N 11 H √ √ √ x x √ √ √ x √
65 Sanum Azzarein P 10-08-2021 N 10 H √ √ √ √ x √ √ √ x √
66 Afika Lidya Putri P 28-08-2021 N 10 H √ √ √ x x √ √ √ x √
67 Fatimah Rayla Zara P 31-08-2021 N 10 H √ √ √ x x √ √ √ x √
68 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 9 H √ √ √ x x √ √ √ x √
69 M. Ardiansyah L 02-10-2021 N 8 H √ √ √ √ x √ √ √ x √
70 M. Iqbal L 31-10-2021 N 8 H √ √ √ √ x √ √ x x √
71 Adzkiy Dinillah L 18-12-2021 N 6 H √ √ √ √ x √ √ x x √
72 Nayyira Zuyyina Salsabila P 21-12-2021 N 6 H √ √ √ √ x √ √ x x √
73 M. Ali Imron L 22-01-2022 N 5 H √ √ √ √ x √ √ x x x
74 M. Salman Farisi L 09-03-2022 N 3 H √ √ √ √ x √ √ x x x
75 Zaqiyatun Nisa P 09-03-2022 N 3 H √ √ √ √ x √ √ x x x
76 A.Shofiul Asmi Alashari L 26-07-2020 K 22 K √ √ √ √ √ √ √ √ x √
77 Nabila Zafira Andini P 17-09-2020 N 21 H √ √ √ x x √ √ √ x √
78 Nayyila Inshira Putri P 10-10-2021 N 20 H √ √ √ x x √ √ x x √
79 Nabila Yahya L 17-11-2020 N 19 H √ √ √ x x √ √ √ x √
80 M.Zafran Alydin L 10-12-2020 N 19 H √ √ √ x x √ √ √ x √
81 3317060901210004 Salman Usmani L 09-01-2021 N 17 H √ √ √ x x √ √ √ √ √
82 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 16 H √ √ √ x x √ √ √ x √
83 Humaira Rahma P 03-03-2021 N 14 H √ √ √ x x √ √ √ x √
84 Usman Faqih Abdillah L 25-03-2021 N 14 H √ √ √ x x √ √ x x √
85 Muhammad Kenzo Alvaro L 04-05-2021 N 12 H √ √ √ x x √ √ √ x √
86 Muhammad Faisal Hakim L 05-06-2021 K 12 K √ √ √ √ √ √ √ √ x √
87 Muhammad Mazzin Mujtaba L 25-06-2021 N 11 H √ √ √ x x √ √ √ x √
88 M. Hazin Musaddad L 15-07-2021 N 11 H √ √ √ x x √ √ √ x √
 89 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 10 H √ √ √ x x √ √ √ x √
90 Nur Laila Atiya P 10-08-2021 K 10 K √ √ √ √ √ √ √ x x √
91 Hibatul Maula P 13-11-2021 N 7 H √ √ √ x x √ √ x x √
92 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 7 H √ √ √ x x √ √ x √ √
93 Muhammad Najid Fayyad L 27-11-2021 N 6 H √ √ √ x x √ √ x x √
94 Ahnaf Nufayyi' L 04-01-2022 N 5 H √ √ √ √ x √ √ x x x
95 Naswa Yumna Ramadhani P 22-04-2022 N 2 H √ √ √ √ x √ √ x x x
96 Ahmad Sirojudin Aqil L 26-06-2020 N 23 H √ √ √ √ x √ √ √ x √
97 M.Mirzani Al-Afasi L 09-07-2020 N 22 H √ √ √ x x √ √ √ x √
98 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 17 H √ √ √ x x √ √ √ x √
99 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 17 M √ √ √ √ √ √ √ √ x √
100 Karina Mazaya Dzakiyah P 23-12-2020 N 17 H √ √ √ x x √ √ √ x √
101 Danial Abdul Syakur Asif L 26-12-2020 N 17 H √ √ √ x x √ √ √ x √
102 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 13 H √ √ √ x x √ √ √ x √
103 3317062405210002 Azka Latiful Umam L 24-05-2021 N 13 H √ √ √ √ x √ √ √ x √
104 Asna Khusnin Nada P 25-06-2021 N 11 H √ √ √ √ x √ √ √ x √
105 3317065909210002 Widdatul Ulya P 19-09-2021 N 9 H √ √ √ √ x √ √ √ x √
106 BY. Nurul Maunah L 13-02-2022 N 4 H √ √ √ x x √ √ x x x
107 Umi Habibah P 25-03-2022 N 3 H √ √ √ x x √ √ x x x

Sidorejo, 30 Juni 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 0
K 9 7
98
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : JULI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Muhammad Ridho Rafian L 13-08-2020 N 23 H √ √ √ √ x √ √ √ x √
2 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 22 H √ √ √ √ x √ √ √ x √
4 Nabila Asna P 25-08-2020 N 22 H √ √ √ √ x √ √ √ x √
5 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 22 H √ √ √ x x √ √ √ x √
6 Azam Maulana Putra L 24-09-2020 N 21 H √ √ √ x x √ √ √ x √
7 Danis Ahmad Faisal L 25-09-2020 N 21 H √ √ √ x x √ √ √ x √
8 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 21 H √ √ √ x x √ √ √ x √
9 M.Ridwan Alfaris L 07-11-2020 N 20 H √ √ √ x x √ √ √ x √
10 Asna Maulidya Putri P 29-11-2020 N 20 H √ √ √ x x √ √ √ x √
11 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 17 H √ √ √ x x √ √ √ x √
12 Ahmad Farhan Alalifi L 23-02-2021 N 16 H √ √ √ x x √ √ √ x √
13 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 16 H √ √ √ x x √ √ √ x √
14 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 16 H √ √ √ √ x √ √ √ x √
15 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 16 H √ √ √ x x √ √ √ x √
16 Farha Nisyatul Mazaya P 05-03-2021 N 16 H √ √ √ √ x √ √ √ x √
17 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 15 H √ √ √ x x √ √ √ x √
18 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 14 H √ √ √ x x √ √ √ x √
19 Yumna Ziyanada Kalisa P 28-04-2021 N 14 H √ √ √ x x √ √ √ x √
20 M. Azmi Alfarizi L 18-05-2021 N 13 H √ √ √ x x √ √ √ x √
21 Ahmad Mushollin L 19-06-2021 N 12 H √ √ √ √ x √ √ √ x √
22 Maryam Eliza Khasanah P 27-06-2021 N 12 H √ √ √ √ x √ √ √ x √
23 Niko Rafif Pratama L 19-07-2021 N 11 H √ √ √ √ x √ √ √ x √
24 Ahmad Diyaunnas L 06-08-2021 N 11 H √ √ √ √ x √ √ √ x √
25 Muhammad Rosikhul Ulum L 07-08-2021 N 11 H √ √ √ x x √ √ √ x √
26 Laila Wasiatun Maghfiroh L 12-09-2021 N 10 H √ √ √ x x √ √ √ x √
27 Muhammad Syadid L 13-09-2021 K 10 K √ √ √ √ √ √ √ √ x √
28 Farel Ahmad Fatian L 18-09-2021 N 10 H √ √ √ x x √ √ √ x √
29 Seva Tia Azzahra P 18-09-2021 N 10 H √ √ √ √ x √ √ √ x √
30 Muhammad Muhtar Alhaq L 01-10-2021 N 9 H √ √ √ x x √ √ x x √
31 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 9 H √ √ √ √ x √ √ x x √
32 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 8 H √ √ √ √ x √ √ x x √
33 Adiba Zahrotut Tazkiyah P 09-11-2021 N 8 H √ √ √ x x √ √ x x √
34 M. Dias Arsyad L 09-11-2021 N 8 H √ √ √ √ x √ √ x x √
35 Muhammad Fathan Alvaro L 04-12-2021 K 7 K √ √ √ √ √ √ √ x x √
36 Kenzu Febrian Alfarizqi L 13-02-2022 N 5 H √ √ √ √ x √ √ x x x
37 Raisa Malinda Ramadhani P 02-04-2022 N 3 H √ √ √ √ x √ √ x x x
38 Athiqoh Fadhilah P 02-04-2022 N 3 H √ √ √ √ x √ √ x x x
40 Asfa Azkiya Nahda P 19-12-2020 N 19 H √ √ √ x x √ √ √ x √
41 Zaidatul Khusna P 15-11-2020 N 19 H √ √ √ x x √ √ √ x √
42 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 17 H √ √ √ x x √ √ √ x √
43 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 15 H √ √ √ x x √ √ √ x √
44 Qiyana Zahra Athiqoh P 07-05-2021 K 13 K √ √ √ √ √ √ √ √ x √
45 Hilyatun Nisa P 20-10-2021 K 8 M √ √ √ √ √ √ √ √ x √
46 Aisyah Humaira P 20-10-2021 N 8 H √ √ √ √ x √ √ x x √
47 Thifa Ulya P 21-12-2021 N 7 H √ √ √ √ x √ √ x x √
48 Fabian Azmi L 30-12-2021 N 7 H √ √ √ √ x √ √ x x √
49 Syauqi Ramadhan L 06-04-2022 N 3 H √ √ √ √ x √ √ x x x
50 3317062709200001 M.Miftahul Huda L 27-09-2020 N 23 H √ √ √ √ x √ √ √ x √
51 3317065710200001 Fikrotul Kamilah P 17-10-2020 N 23 H √ √ √ √ x √ √ √ x √
52 3317062910200001 M.Fatin Kamil L 29-10-2020 N 20 H √ √ √ x x √ √ √ x √
53 Aina Mardiyah P 05-11-2020 K 19 K √ √ √ √ √ √ √ √ x √
54 M. Zidni Huda L 06-11-2020 N 19 H √ √ √ x x √ √ √ x √
55 3317062911200001 M.Chasan Jamil L 29-11-2020 N 19 H √ √ √ x x √ √ √ x √
56 Fatimah Yaqut Fahriyani P 08-01-2021 N 18 H √ √ √ x x √ √ √ x √
57 3317066001210001 Fina Saadah P 20-01-2021 N 17 H √ √ √ x x √ √ √ x √
58 3317061402210002 M. Idror L 14-02-2021 N 17 H √ √ √ x x √ √ √ x √
59 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 14 H √ √ √ x x √ √ √ x √
60 Aisyah Najla Rosyidah P 15-05-2021 N 14 H √ √ √ x x √ √ √ x √
61 Alifia Nazla Nurul Ilmi P 30-05-2021 N 13 H √ √ √ x x √ √ √ x √
62 Adzkiya Noura Umar P 06-07-2021 N 12 H √ √ √ x x √ √ √ x √
63 Muh. Asyraf Tsaquf L 07-07-2021 N 12 H √ √ √ x x √ √ √ x √
64 Dina Putri Aulia P 23-07-2021 N 12 H √ √ √ x x √ √ √ x √
65 Sanum Azzarein P 10-08-2021 N 11 H √ √ √ √ x √ √ √ x √
66 Afika Lidya Putri P 28-08-2021 N 11 H √ √ √ x x √ √ √ x √
67 Fatimah Rayla Zara P 31-08-2021 N 11 H √ √ √ x x √ √ √ x √
68 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 10 H √ √ √ x x √ √ √ x √
69 M. Ardiansyah L 02-10-2021 N 9 H √ √ √ √ x √ √ √ x √
70 M. Iqbal L 31-10-2021 N 9 H √ √ √ √ x √ √ x x √
71 Adzkiy Dinillah L 18-12-2021 N 7 H √ √ √ √ x √ √ x x √
72 Nayyira Zuyyina Salsabila P 21-12-2021 N 7 H √ √ √ √ x √ √ x x √
73 M. Ali Imron L 22-01-2022 N 6 H √ √ √ √ x √ √ x x √
74 M. Salman Farisi L 09-03-2022 N 4 H √ √ √ √ x √ √ x x x
75 Zaqiyatun Nisa P 09-03-2022 N 4 H √ √ √ √ x √ √ x x x
76 A.Shofiul Asmi Alashari L 26-07-2020 K 23 K √ √ √ √ √ √ √ √ x √
77 Nabila Zafira Andini P 17-09-2020 N 22 H √ √ √ x x √ √ √ x √
78 Nayyila Inshira Putri P 10-10-2021 N 21 H √ √ √ x x √ √ x x √
79 Nabila Yahya L 17-11-2020 N 20 H √ √ √ x x √ √ √ x √
80 M.Zafran Alydin L 10-12-2020 N 20 H √ √ √ x x √ √ √ x √
81 3317060901210004 Salman Usmani L 09-01-2021 N 18 H √ √ √ x x √ √ √ √ √
82 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 17 H √ √ √ x x √ √ √ x √
83 Humaira Rahma P 03-03-2021 N 15 H √ √ √ x x √ √ √ x √
84 Usman Faqih Abdillah L 25-03-2021 N 15 H √ √ √ x x √ √ x x √
85 Muhammad Kenzo Alvaro L 04-05-2021 N 13 H √ √ √ x x √ √ √ x √
86 Muhammad Faisal Hakim L 05-06-2021 K 13 K √ √ √ √ √ √ √ √ x √
87 Muhammad Mazzin Mujtaba L 25-06-2021 N 12 H √ √ √ x x √ √ √ x √
88 M. Hazin Musaddad L 15-07-2021 N 12 H √ √ √ x x √ √ √ x √
89 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 11 H √ √ √ x x √ √ √ x √
90 Nur Laila Atiya P 10-08-2021 K 11 K √ √ √ √ √ √ √ x x √
 91 Hibatul Maula P 13-11-2021 N 8 H √ √ √ x x √ √ x x √
92 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 8 H √ √ √ x x √ √ x √ √
93 Muhammad Najid Fayyad L 27-11-2021 N 7 H √ √ √ x x √ √ x x √
94 Ahnaf Nufayyi' L 04-01-2022 N 6 H √ √ √ √ x √ √ x x √
95 Naswa Yumna Ramadhani P 22-04-2022 N 3 H √ √ √ √ x √ √ x x x
97 M.Mirzani Al-Afasi L 09-07-2020 N 23 H √ √ √ x x √ √ √ x √
98 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 18 H √ √ √ x x √ √ √ x √
99 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 18 M √ √ √ √ √ √ √ √ x √
100 Karina Mazaya Dzakiyah P 23-12-2020 N 18 H √ √ √ x x √ √ √ x √
101 Danial Abdul Syakur Asif L 26-12-2020 N 18 H √ √ √ x x √ √ √ x √
102 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 14 H √ √ √ x x √ √ √ x √
103 3317062405210002 Azka Latiful Umam L 24-05-2021 N 14 H √ √ √ √ x √ √ √ x √
104 Asna Khusnin Nada P 25-06-2021 N 12 H √ √ √ √ x √ √ √ x √
105 3317065909210002 Widdatul Ulya P 19-09-2021 N 10 H √ √ √ √ x √ √ √ x √
106 BY. Nurul Maunah L 13-02-2022 N 5 H √ √ √ x x √ √ x x x
107 Umi Habibah P 25-03-2022 N 4 H √ √ √ x x √ √ x x x

Sidorejo, 31 Juli 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 0
K 9 7
95
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : AGUSTUS
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317065309200001 Wafiyatul Faizah P 13-08-2020 N 23 H √ √ √ √ x √ √ √ x √
2 Nabila Asna P 25-08-2020 N 23 H √ √ √ √ x √ √ √ x √
3 3317067008200003 Afizah Khairana Latifah P 30-08-2020 N 23 H √ √ √ x x √ √ √ x √
4 Azam Maulana Putra L 24-09-2020 N 22 H √ √ √ x x √ √ √ x √
5 Danis Ahmad Faisal L 25-09-2020 N 22 H √ √ √ x x √ √ √ x √
6 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 22 H √ √ √ x x √ √ √ x √
7 M.Ridwan Alfaris L 07-11-2020 N 21 H √ √ √ x x √ √ √ x √
8 Asna Maulidya Putri P 29-11-2020 N 21 H √ √ √ x x √ √ √ x √
9 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 18 H √ √ √ x x √ √ √ x √
10 Ahmad Farhan Alalifi L 23-02-2021 N 17 H √ √ √ x x √ √ √ x √
11 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 17 H √ √ √ x x √ √ √ x √
12 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 17 H √ √ √ √ x √ √ √ x √
13 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 17 H √ √ √ x x √ √ √ x √
14 Farha Nisyatul Mazaya P 05-03-2021 N 17 H √ √ √ √ x √ √ √ x √
15 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 16 H √ √ √ x x √ √ √ x √
16 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 15 H √ √ √ x x √ √ √ x √
17 Yumna Ziyanada Kalisa P 28-04-2021 N 15 H √ √ √ x x √ √ √ x √
18 M. Azmi Alfarizi L 18-05-2021 N 14 H √ √ √ x x √ √ √ x √
19 Ahmad Mushollin L 19-06-2021 N 13 H √ √ √ √ x √ √ √ x √
20 Maryam Eliza Khasanah P 27-06-2021 N 13 H √ √ √ √ x √ √ √ x √
21 Niko Rafif Pratama L 19-07-2021 N 12 H √ √ √ √ x √ √ √ x √
22 Ahmad Diyaunnas L 06-08-2021 N 12 H √ √ √ √ x √ √ √ x √
23 Muhammad Rosikhul Ulum L 07-08-2021 N 12 H √ √ √ x x √ √ √ x √
24 Laila Wasiatun Maghfiroh L 12-09-2021 N 11 H √ √ √ x x √ √ √ x √
25 Muhammad Syadid L 13-09-2021 K 11 K √ √ √ √ √ √ √ √ x √
26 Farel Ahmad Fatian L 18-09-2021 N 11 H √ √ √ x x √ √ √ x √
27 Seva Tia Azzahra P 18-09-2021 N 11 H √ √ √ √ x √ √ √ x √
28 Muhammad Muhtar Alhaq L 01-10-2021 N 10 H √ √ √ x x √ √ x x √
29 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 10 H √ √ √ √ x √ √ x x √
30 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 9 H √ √ √ √ x √ √ x x √
31 Adiba Zahrotut Tazkiyah P 09-11-2021 N 9 H √ √ √ x x √ √ x x √
32 M. Dias Arsyad L 09-11-2021 N 9 H √ √ √ √ x √ √ x x √
33 Muhammad Fathan Alvaro L 04-12-2021 K 8 K √ √ √ √ √ √ √ x x √
34 Kenzu Febrian Alfarizqi L 13-02-2022 N 6 H √ √ √ √ x √ √ x x √
35 Raisa Malinda Ramadhani P 02-04-2022 N 4 H √ √ √ √ x √ √ x x x
36 Athiqoh Fadhilah P 02-04-2022 N 4 H √ √ √ √ x √ √ x x x
37 Asfa Azkiya Nahda P 19-12-2020 N 20 H √ √ √ x x √ √ √ x √
38 Zaidatul Khusna P 15-11-2020 N 20 H √ √ √ x x √ √ √ x √
39 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 18 H √ √ √ x x √ √ √ x √
40 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 16 H √ √ √ x x √ √ √ x √
41 Qiyana Zahra Athiqoh P 07-05-2021 K 14 K √ √ √ √ √ √ √ √ x √
42 Hilyatun Nisa P 20-10-2021 K 9 M √ √ √ √ √ √ √ √ x √
43 Aisyah Humaira P 20-10-2021 N 9 H √ √ √ √ x √ √ x x √
44 Thifa Ulya P 21-12-2021 N 8 H √ √ √ √ x √ √ x x √
45 Fabian Azmi L 30-12-2021 N 8 H √ √ √ √ x √ √ x x √
46 Syauqi Ramadhan L 06-04-2022 N 4 H √ √ √ √ x √ √ x x x
47 3317062910200001 M.Fatin Kamil L 29-10-2020 N 21 H √ √ √ x x √ √ √ x √
48 Aina Mardiyah P 05-11-2020 K 20 K √ √ √ √ √ √ √ √ x √
49 M. Zidni Huda L 06-11-2020 N 20 H √ √ √ x x √ √ √ x √
50 3317062911200001 M.Chasan Jamil L 29-11-2020 N 20 H √ √ √ x x √ √ √ x √
51 Fatimah Yaqut Fahriyani P 08-01-2021 N 19 H √ √ √ x x √ √ √ x √
52 3317066001210001 Fina Saadah P 20-01-2021 N 18 H √ √ √ x x √ √ √ x √
53 3317061402210002 M. Idror L 14-02-2021 N 18 H √ √ √ x x √ √ √ x √
54 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 15 H √ √ √ x x √ √ √ x √
55 Aisyah Najla Rosyidah P 15-05-2021 N 15 H √ √ √ x x √ √ √ x √
56 Alifia Nazla Nurul Ilmi P 30-05-2021 N 14 H √ √ √ x x √ √ √ x √
57 Adzkiya Noura Umar P 06-07-2021 N 13 H √ √ √ x x √ √ √ x √
58 Muh. Asyraf Tsaquf L 07-07-2021 N 13 H √ √ √ x x √ √ √ x √
59 Dina Putri Aulia P 23-07-2021 N 13 H √ √ √ x x √ √ √ x √
60 Sanum Azzarein P 10-08-2021 N 12 H √ √ √ √ x √ √ √ x √
61 Afika Lidya Putri P 28-08-2021 N 12 H √ √ √ x x √ √ √ x √
62 Fatimah Rayla Zara P 31-08-2021 N 12 H √ √ √ x x √ √ √ x √
63 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 11 H √ √ √ x x √ √ √ x √
64 M. Ardiansyah L 02-10-2021 N 10 H √ √ √ √ x √ √ √ x √
65 M. Iqbal L 31-10-2021 N 10 H √ √ √ √ x √ √ x x √
66 Adzkiy Dinillah L 18-12-2021 N 10 H √ √ √ √ x √ √ x x √
67 Nayyira Zuyyina Salsabila P 21-12-2021 N 8 H √ √ √ √ x √ √ x x √
68 M. Ali Imron L 22-01-2022 N 7 H √ √ √ √ x √ √ x x √
69 M. Salman Farisi L 09-03-2022 N 5 H √ √ √ √ x √ √ x x x
70 Zaqiyatun Nisa P 09-03-2022 N 5 H √ √ √ √ x √ √ x x x
71 Nabila Zafira Andini P 17-09-2020 N 23 H √ √ √ x x √ √ √ x √
72 Nayyila Inshira Putri P 10-10-2021 N 22 H √ √ √ x x √ √ x x √
73 Nabila Yahya L 17-11-2020 N 21 H √ √ √ x x √ √ √ x √
74 M.Zafran Alydin L 10-12-2020 N 21 H √ √ √ x x √ √ √ x √
75 3317060901210004 Salman Usmani L 09-01-2021 N 19 H √ √ √ x x √ √ √ √ √
76 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 18 H √ √ √ x x √ √ √ x √
77 Humaira Rahma P 03-03-2021 N 16 H √ √ √ x x √ √ √ x √
78 Usman Faqih Abdillah L 25-03-2021 N 16 H √ √ √ x x √ √ x x √
79 Muhammad Kenzo Alvaro L 04-05-2021 N 14 H √ √ √ x x √ √ √ x √
80 Muhammad Faisal Hakim L 05-06-2021 K 14 K √ √ √ √ √ √ √ √ x √
81 Muhammad Mazzin Mujtaba L 25-06-2021 N 13 H √ √ √ x x √ √ √ x √
82 M. Hazin Musaddad L 15-07-2021 N 13 H √ √ √ x x √ √ √ x √
83 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 12 H √ √ √ x x √ √ √ x √
84 Nur Laila Atiya P 10-08-2021 K 12 K √ √ √ √ √ √ √ x x √
85 Hibatul Maula P 13-11-2021 N 9 H √ √ √ x x √ √ x x √
86 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 9 H √ √ √ x x √ √ x √ √
87 Muhammad Najid Fayyad L 27-11-2021 N 8 H √ √ √ x x √ √ x x √
88 Ahnaf Nufayyi' L 04-01-2022 N 7 H √ √ √ √ x √ √ x x √
89 Naswa Yumna Ramadhani P 22-04-2022 N 4 H √ √ √ √ x √ √ x x x
90 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 19 H √ √ √ x x √ √ √ x √
91 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 19 M √ √ √ √ √ √ √ √ x √
92 Karina Mazaya Dzakiyah P 23-12-2020 N 19 H √ √ √ x x √ √ √ x √
93 Danial Abdul Syakur Asif L 26-12-2020 N 19 H √ √ √ x x √ √ √ x √
94 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 15 H √ √ √ x x √ √ √ x √
95 3317062405210002 Azka Latiful Umam L 24-05-2021 N 15 H √ √ √ √ x √ √ √ x √
96 Asna Khusnin Nada P 25-06-2021 N 13 H √ √ √ √ x √ √ √ x √
97 3317065909210002 Widdatul Ulya P 19-09-2021 N 11 H √ √ √ √ x √ √ √ x √
98 BY. Nurul Maunah L 13-02-2022 N 6 H √ √ √ x x √ √ x x √
99 Umi Habibah P 25-03-2022 N 5 H √ √ √ x x √ √ x x x

Sidorejo, 31 Agustus 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 0
K 8 6
91
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : SEPTEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Azam Maulana Putra L 24-09-2020 N 23 H √ √ √ x x √ √ √ x √
2 Danis Ahmad Faisal L 25-09-2020 N 23 H √ √ √ x x √ √ √ x √
3 3317060410200001 Ahmad Fatih Nabhana Syadila L 04-10-2020 N 23 H √ √ √ x x √ √ √ x √
4 M.Ridwan Alfaris L 07-11-2020 N 22 H √ √ √ x x √ √ √ x √
5 Asna Maulidya Putri P 29-11-2020 N 22 H √ √ √ x x √ √ √ x √
6 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 N 19 H √ √ √ x x √ √ √ x √
7 Ahmad Farhan Alalifi L 23-02-2021 N 18 H √ √ √ x x √ √ √ x √
8 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 18 H √ √ √ x x √ √ √ x √
9 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 18 H √ √ √ √ x √ √ √ x √
10 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 18 H √ √ √ x x √ √ √ x √
11 Farha Nisyatul Mazaya P 05-03-2021 N 18 H √ √ √ √ x √ √ √ x √
12 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 N 17 H √ √ √ x x √ √ √ x √
13 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 16 H √ √ √ x x √ √ √ x √
14 Yumna Ziyanada Kalisa P 28-04-2021 N 16 H √ √ √ x x √ √ √ x √
15 M. Azmi Alfarizi L 18-05-2021 N 15 H √ √ √ x x √ √ √ x √
16 Ahmad Mushollin L 19-06-2021 N 14 H √ √ √ √ x √ √ √ x √
17 Maryam Eliza Khasanah P 27-06-2021 N 14 H √ √ √ √ x √ √ √ x √
18 Niko Rafif Pratama L 19-07-2021 N 13 H √ √ √ √ x √ √ √ x √
19 Ahmad Diyaunnas L 06-08-2021 N 13 H √ √ √ √ x √ √ √ x √
20 Muhammad Rosikhul Ulum L 07-08-2021 N 13 H √ √ √ x x √ √ √ x √
21 Laila Wasiatun Maghfiroh L 12-09-2021 N 12 H √ √ √ x x √ √ √ x √
22 Muhammad Syadid L 13-09-2021 K 12 K √ √ √ √ √ √ √ √ x √
23 Farel Ahmad Fatian L 18-09-2021 N 12 H √ √ √ x x √ √ √ x √
24 Seva Tia Azzahra P 18-09-2021 N 12 H √ √ √ √ x √ √ √ x √
25 Muhammad Muhtar Alhaq L 01-10-2021 N 11 H √ √ √ x x √ √ x x √
26 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 11 H √ √ √ √ x √ √ x x √
27 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 10 H √ √ √ √ x √ √ x x √
28 Adiba Zahrotut Tazkiyah P 09-11-2021 N 10 H √ √ √ x x √ √ x x √
29 M. Dias Arsyad L 09-11-2021 N 10 H √ √ √ √ x √ √ x x √
30 Muhammad Fathan Alvaro L 04-12-2021 K 9 K √ √ √ √ √ √ √ x x √
31 Kenzu Febrian Alfarizqi L 13-02-2022 N 7 H √ √ √ √ x √ √ x x √
32 Raisa Malinda Ramadhani P 02-04-2022 K 5 K √ √ √ √ √ √ √ x x x
33 Athiqoh Fadhilah P 02-04-2022 N 5 H √ √ √ √ x √ √ x x x
34 Asfa Azkiya Nahda P 19-12-2020 N 21 H √ √ √ x x √ √ √ x √
35 Zaidatul Khusna P 15-11-2020 N 21 H √ √ √ x x √ √ √ x √
36 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 19 H √ √ √ x x √ √ √ x √
37 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 17 H √ √ √ x x √ √ √ x √
38 Qiyana Zahra Athiqoh P 07-05-2021 K 15 K √ √ √ √ √ √ √ √ x √
39 Hilyatun Nisa P 20-10-2021 N 10 H √ √ √ √ √ √ √ √ x √
40 Aisyah Humaira P 20-10-2021 N 10 H √ √ √ √ x √ √ x x √
41 Thifa Ulya P 21-12-2021 N 9 H √ √ √ √ x √ √ x x √
42 Fabian Azmi L 30-12-2021 N 9 H √ √ √ √ x √ √ x x √
43 Syauqi Ramadhan L 06-04-2022 N 5 H √ √ √ √ x √ √ x x x
44 3317062910200001 M.Fatin Kamil L 29-10-2020 N 22 H √ √ √ x x √ √ √ x √
45 Aina Mardiyah P 05-11-2020 K 21 K √ √ √ √ √ √ √ √ x √
46 M. Zidni Huda L 06-11-2020 N 21 H √ √ √ x x √ √ √ x √
47 3317062911200001 M.Chasan Jamil L 29-11-2020 N 21 H √ √ √ x x √ √ √ x √
48 Fatimah Yaqut Fahriyani P 08-01-2021 N 20 H √ √ √ x x √ √ √ x √
49 3317066001210001 Fina Saadah P 20-01-2021 N 19 H √ √ √ x x √ √ √ x √
50 3317061402210002 M. Idror L 14-02-2021 N 19 H √ √ √ x x √ √ √ x √
51 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 16 H √ √ √ x x √ √ √ x √
52 Aisyah Najla Rosyidah P 15-05-2021 N 16 H √ √ √ x x √ √ √ x √
53 Alifia Nazla Nurul Ilmi P 30-05-2021 N 15 H √ √ √ x x √ √ √ x √
54 Adzkiya Noura Umar P 06-07-2021 N 14 H √ √ √ x x √ √ √ x √
55 Muh. Asyraf Tsaquf L 07-07-2021 N 14 H √ √ √ x x √ √ √ x √
56 Dina Putri Aulia P 23-07-2021 N 14 H √ √ √ x x √ √ √ x √
57 Sanum Azzarein P 10-08-2021 N 13 H √ √ √ √ x √ √ √ x √
58 Afika Lidya Putri P 28-08-2021 N 13 H √ √ √ x x √ √ √ x √
59 Fatimah Rayla Zara P 31-08-2021 N 13 H √ √ √ x x √ √ √ x √
60 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 12 H √ √ √ x x √ √ √ x √
61 M. Ardiansyah L 02-10-2021 N 11 H √ √ √ √ x √ √ √ x √
62 M. Iqbal L 31-10-2021 N 11 H √ √ √ √ x √ √ x x √
63 Adzkiy Dinillah L 18-12-2021 N 11 H √ √ √ √ x √ √ x x √
64 Nayyira Zuyyina Salsabila P 21-12-2021 N 9 H √ √ √ √ x √ √ x x √
65 M. Ali Imron L 22-01-2022 N 8 H √ √ √ √ x √ √ x x √
66 M. Salman Farisi L 09-03-2022 N 6 H √ √ √ √ x √ √ x x √
67 Zaqiyatun Nisa P 09-03-2022 N 6 H √ √ √ √ x √ √ x x √
68 Nayyila Inshira Putri P 10-10-2021 N 23 H √ √ √ x x √ √ x x √
69 Nabila Yahya L 17-11-2020 N 22 H √ √ √ x x √ √ √ x √
70 M.Zafran Alydin L 10-12-2020 N 22 H √ √ √ x x √ √ √ x √
71 3317060901210004 Salman Usmani L 09-01-2021 N 20 H √ √ √ x x √ √ √ √ √
72 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 19 H √ √ √ x x √ √ √ x √
73 Humaira Rahma P 03-03-2021 N 17 H √ √ √ x x √ √ √ x √
74 Usman Faqih Abdillah L 25-03-2021 N 17 H √ √ √ x x √ √ x x √
75 Muhammad Kenzo Alvaro L 04-05-2021 N 15 H √ √ √ x x √ √ √ x √
76 Muhammad Faisal Hakim L 05-06-2021 K 15 K √ √ √ √ √ √ √ √ x √
77 Muhammad Mazzin Mujtaba L 25-06-2021 N 14 H √ √ √ x x √ √ √ x √
78 M. Hazin Musaddad L 15-07-2021 N 14 H √ √ √ x x √ √ √ x √
79 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 13 H √ √ √ x x √ √ √ x √
80 Nur Laila Atiya P 10-08-2021 K 13 M √ √ √ √ √ √ √ x x √
81 Hibatul Maula P 13-11-2021 K 10 K √ √ √ x √ √ √ x x √
82 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 10 H √ √ √ x x √ √ x √ √
83 Muhammad Najid Fayyad L 27-11-2021 N 9 H √ √ √ x x √ √ x x √
84 Ahnaf Nufayyi' L 04-01-2022 N 8 H √ √ √ √ x √ √ x x √
85 Naswa Yumna Ramadhani P 22-04-2022 N 5 H √ √ √ √ x √ √ x x x
86 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 20 H √ √ √ x x √ √ √ x √
87 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 20 M √ √ √ √ √ √ √ √ x √
88 Karina Mazaya Dzakiyah P 23-12-2020 N 20 H √ √ √ x x √ √ √ x √
89 Danial Abdul Syakur Asif L 26-12-2020 N 20 H √ √ √ x x √ √ √ x √
90 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 16 H √ √ √ x x √ √ √ x √
91 3317062405210002 Azka Latiful Umam L 24-05-2021 N 16 H √ √ √ √ x √ √ √ x √
92 Asna Khusnin Nada P 25-06-2021 N 14 H √ √ √ √ x √ √ √ x √
93 3317065909210002 Widdatul Ulya P 19-09-2021 N 12 H √ √ √ √ x √ √ √ x √
94 BY. Nurul Maunah L 13-02-2022 N 7 H √ √ √ x x √ √ x x √
95 Umi Habibah P 25-03-2022 N 6 H √ √ √ x x √ √ x x √

Sidorejo, 30 September 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 0
K 9 7
86
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : OKTOBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 M.Ridwan Alfaris L 07-11-2020 N 23 H √ √ √ x x √ √ √ x √
2 Asna Maulidya Putri P 29-11-2020 N 23 H √ √ √ x x √ √ √ x √
3 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 K 20 K √ √ √ x √ √ √ √ x √
4 Ahmad Farhan Alalifi L 23-02-2021 N 19 H √ √ √ x x √ √ √ x √
5 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 19 H √ √ √ x x √ √ √ x √
6 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 19 H √ √ √ √ x √ √ √ x √
7 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 19 H √ √ √ x x √ √ √ x √
8 Farha Nisyatul Mazaya P 05-03-2021 N 19 H √ √ √ √ x √ √ √ x √
9 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 K 18 K √ √ √ x √ √ √ √ x √
10 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 17 H √ √ √ x x √ √ √ x √
11 Yumna Ziyanada Kalisa P 28-04-2021 N 17 H √ √ √ x x √ √ √ x √
12 M. Azmi Alfarizi L 18-05-2021 K 16 K √ √ √ x √ √ √ √ x √
13 Ahmad Mushollin L 19-06-2021 N 15 H √ √ √ √ x √ √ √ x √
14 Maryam Eliza Khasanah P 27-06-2021 N 15 H √ √ √ √ x √ √ √ x √
15 Niko Rafif Pratama L 19-07-2021 N 14 H √ √ √ √ x √ √ √ x √
16 Ahmad Diyaunnas L 06-08-2021 N 14 H √ √ √ √ x √ √ √ x √
17 Muhammad Rosikhul Ulum L 07-08-2021 N 14 H √ √ √ x x √ √ √ x √
18 Laila Wasiatun Maghfiroh L 12-09-2021 N 13 H √ √ √ x x √ √ √ x √
19 Muhammad Syadid L 13-09-2021 N 13 H √ √ √ √ x √ √ √ x √
20 Farel Ahmad Fatian L 18-09-2021 N 13 H √ √ √ x x √ √ √ x √
21 Seva Tia Azzahra P 18-09-2021 N 13 H √ √ √ √ x √ √ √ x √
22 Muhammad Muhtar Alhaq L 01-10-2021 N 12 H √ √ √ x x √ √ x x √
23 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 12 H √ √ √ √ x √ √ x x √
24 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 11 H √ √ √ √ x √ √ x x √
25 Adiba Zahrotut Tazkiyah P 09-11-2021 N 11 H √ √ √ x x √ √ x x √
26 M. Dias Arsyad L 09-11-2021 K 11 K √ √ √ √ √ √ √ x x √
27 Muhammad Fathan Alvaro L 04-12-2021 N 10 H √ √ √ √ √ √ √ x x √
28 Kenzu Febrian Alfarizqi L 13-02-2022 N 8 H √ √ √ √ x √ √ x x √
29 Raisa Malinda Ramadhani P 02-04-2022 K 6 K √ √ √ √ √ √ √ x x √
30 Athiqoh Fadhilah P 02-04-2022 N 6 H √ √ √ √ x √ √ x x √
31 Asfa Azkiya Nahda P 19-12-2020 N 22 H √ √ √ x x √ √ √ x √
32 Zaidatul Khusna P 15-11-2020 N 22 H √ √ √ x x √ √ √ x √
33 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 20 H √ √ √ x x √ √ √ x √
34 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 18 H √ √ √ x x √ √ √ x √
35 Qiyana Zahra Athiqoh P 07-05-2021 K 16 K √ √ √ √ √ √ √ √ x √
36 Hilyatun Nisa P 20-10-2021 N 11 H √ √ √ √ √ √ √ √ x √
37 Aisyah Humaira P 20-10-2021 N 11 H √ √ √ √ x √ √ x x √
38 Thifa Ulya P 21-12-2021 N 10 H √ √ √ √ x √ √ x x √
39 Fabian Azmi L 30-12-2021 N 10 H √ √ √ √ x √ √ x x √
40 Syauqi Ramadhan L 06-04-2022 N 6 H √ √ √ √ x √ √ x x x
41 3317062910200001 M.Fatin Kamil L 29-10-2020 N 23 H √ √ √ x x √ √ √ x √
42 Aina Mardiyah P 05-11-2020 K 22 K √ √ √ √ √ √ √ √ x √
43 M. Zidni Huda L 06-11-2020 N 22 H √ √ √ x x √ √ √ x √
44 3317062911200001 M.Chasan Jamil L 29-11-2020 N 22 H √ √ √ x x √ √ √ x √
45 Fatimah Yaqut Fahriyani P 08-01-2021 N 21 H √ √ √ x x √ √ √ x √
46 3317066001210001 Fina Saadah P 20-01-2021 S 20 M √ √ √ x √ √ √ √ x √
47 3317061402210002 M. Idror L 14-02-2021 N 20 H √ √ √ x x √ √ √ x √
48 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 17 H √ √ √ x x √ √ √ x √
49 Aisyah Najla Rosyidah P 15-05-2021 N 17 H √ √ √ x x √ √ √ x √
50 Alifia Nazla Nurul Ilmi P 30-05-2021 N 16 H √ √ √ x x √ √ √ x √
51 Adzkiya Noura Umar P 06-07-2021 N 15 H √ √ √ x x √ √ √ x √
52 Muh. Asyraf Tsaquf L 07-07-2021 K 15 K √ √ √ x √ √ √ √ x √
53 Dina Putri Aulia P 23-07-2021 N 15 H √ √ √ x x √ √ √ x √
54 Sanum Azzarein P 10-08-2021 N 14 H √ √ √ √ x √ √ √ x √
55 Afika Lidya Putri P 28-08-2021 N 14 H √ √ √ x x √ √ √ x √
56 Fatimah Rayla Zara P 31-08-2021 N 14 H √ √ √ x x √ √ √ x √
57 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 13 H √ √ √ x x √ √ √ x √
58 M. Ardiansyah L 02-10-2021 N 12 H √ √ √ √ x √ √ √ x √
59 M. Iqbal L 31-10-2021 N 12 H √ √ √ √ x √ √ x x √
60 Adzkiy Dinillah L 18-12-2021 N 12 H √ √ √ √ x √ √ x x √
61 Nayyira Zuyyina Salsabila P 21-12-2021 N 10 H √ √ √ √ x √ √ x x √
62 M. Ali Imron L 22-01-2022 N 9 H √ √ √ √ x √ √ x x √
63 M. Salman Farisi L 09-03-2022 N 7 H √ √ √ √ x √ √ x x √
64 Zaqiyatun Nisa P 09-03-2022 N 7 H √ √ √ √ x √ √ x x √
65 Nabila Yahya L 17-11-2020 N 23 H √ √ √ x x √ √ √ x √
66 M.Zafran Alydin L 10-12-2020 N 23 H √ √ √ x x √ √ √ x √
67 3317060901210004 Salman Usmani L 09-01-2021 N 21 H √ √ √ x x √ √ √ √ √
68 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 20 H √ √ √ x x √ √ √ x √
69 Humaira Rahma P 03-03-2021 N 18 H √ √ √ x x √ √ √ x √
70 Usman Faqih Abdillah L 25-03-2021 N 18 H √ √ √ x x √ √ x x √
71 Muhammad Kenzo Alvaro L 04-05-2021 N 16 H √ √ √ x x √ √ √ x √
72 Muhammad Faisal Hakim L 05-06-2021 K 16 K √ √ √ √ √ √ √ √ x √
73 Muhammad Mazzin Mujtaba L 25-06-2021 N 15 H √ √ √ x x √ √ √ x √
74 M. Hazin Musaddad L 15-07-2021 K 15 K √ √ √ x √ √ √ √ x √
75 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 14 H √ √ √ x x √ √ √ x √
76 Nur Laila Atiya P 10-08-2021 K 14 K √ √ √ √ √ √ √ x x √
77 Hibatul Maula P 13-11-2021 N 11 H √ √ √ x x √ √ x x √
78 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 11 H √ √ √ x x √ √ x √ √
79 Muhammad Najid Fayyad L 27-11-2021 N 10 H √ √ √ x x √ √ x x √
80 Ahnaf Nufayyi' L 04-01-2022 N 9 H √ √ √ √ x √ √ x x √
81 Naswa Yumna Ramadhani P 22-04-2022 N 6 H √ √ √ √ x √ √ x x √
82 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 21 H √ √ √ x x √ √ √ x √
83 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 21 M √ √ √ √ √ √ √ √ x √
84 Karina Mazaya Dzakiyah P 23-12-2020 N 21 H √ √ √ x x √ √ √ x √
85 Danial Abdul Syakur Asif L 26-12-2020 N 21 H √ √ √ x x √ √ √ x √
86 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 17 H √ √ √ x x √ √ √ x √
87 3317062405210002 Azka Latiful Umam L 24-05-2021 N 17 H √ √ √ √ x √ √ √ x √
88 Asna Khusnin Nada P 25-06-2021 N 15 H √ √ √ √ x √ √ √ x √
89 3317065909210002 Widdatul Ulya P 19-09-2021 N 13 H √ √ √ √ x √ √ √ x √
90 BY. Nurul Maunah L 13-02-2022 N 8 H √ √ √ x x √ √ x x √
91 Umi Habibah P 25-03-2022 N 7 H √ √ √ x x √ √ x x √

Sidorejo, 31 Oktober 2022

KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 1
K 12 11
78
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : NOVEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 K 21 K √ √ √ x √ √ √ √ x √
2 Ahmad Farhan Alalifi L 23-02-2021 N 20 H √ √ √ x x √ √ √ x √
3 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 20 H √ √ √ x x √ √ √ x √
4 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 20 H √ √ √ √ x √ √ √ x √
5 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 20 H √ √ √ x x √ √ √ x √
6 Farha Nisyatul Mazaya P 05-03-2021 N 20 H √ √ √ √ x √ √ √ x √
7 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 K 19 K √ √ √ x √ √ √ √ x √
8 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 18 H √ √ √ x x √ √ √ x √
9 Yumna Ziyanada Kalisa P 28-04-2021 N 18 H √ √ √ x x √ √ √ x √
10 M. Azmi Alfarizi L 18-05-2021 K 17 K √ √ √ x √ √ √ √ x √
11 Ahmad Mushollin L 19-06-2021 N 16 H √ √ √ √ x √ √ √ x √
12 Maryam Eliza Khasanah P 27-06-2021 N 16 H √ √ √ √ x √ √ √ x √
13 Niko Rafif Pratama L 19-07-2021 N 15 H √ √ √ √ x √ √ √ x √
14 Ahmad Diyaunnas L 06-08-2021 N 15 H √ √ √ √ x √ √ √ x √
15 Muhammad Rosikhul Ulum L 07-08-2021 N 15 H √ √ √ x x √ √ √ x √
16 Laila Wasiatun Maghfiroh L 12-09-2021 N 14 H √ √ √ x x √ √ √ x √
17 Muhammad Syadid L 13-09-2021 N 14 H √ √ √ √ x √ √ √ x √
18 Farel Ahmad Fatian L 18-09-2021 N 14 H √ √ √ x x √ √ √ x √
19 Seva Tia Azzahra P 18-09-2021 N 14 H √ √ √ √ x √ √ √ x √
20 Muhammad Muhtar Alhaq L 01-10-2021 N 13 H √ √ √ x x √ √ x x √
21 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 13 H √ √ √ √ x √ √ x x √
22 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 12 H √ √ √ √ x √ √ x x √
23 Adiba Zahrotut Tazkiyah P 09-11-2021 N 12 H √ √ √ x x √ √ x x √
24 M. Dias Arsyad L 09-11-2021 K 12 K √ √ √ √ √ √ √ x x √
25 Muhammad Fathan Alvaro L 04-12-2021 N 11 H √ √ √ √ √ √ √ x x √
26 Kenzu Febrian Alfarizqi L 13-02-2022 N 9 H √ √ √ √ x √ √ x x √
27 Raisa Malinda Ramadhani P 02-04-2022 K 7 K √ √ √ √ √ √ √ x x √
28 Athiqoh Fadhilah P 02-04-2022 N 7 H √ √ √ √ x √ √ x x √
29 Asfa Azkiya Nahda P 19-12-2020 N 23 H √ √ √ x x √ √ √ x √
30 Zaidatul Khusna P 15-11-2020 N 23 H √ √ √ x x √ √ √ x √
31 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 21 H √ √ √ x x √ √ √ x √
32 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 19 H √ √ √ x x √ √ √ x √
33 Qiyana Zahra Athiqoh P 07-05-2021 K 17 K √ √ √ √ √ √ √ √ x √
34 Hilyatun Nisa P 20-10-2021 N 12 H √ √ √ √ √ √ √ √ x √
35 Aisyah Humaira P 20-10-2021 N 12 H √ √ √ √ x √ √ x x √
36 Thifa Ulya P 21-12-2021 N 11 H √ √ √ √ x √ √ x x √
37 Fabian Azmi L 30-12-2021 N 11 H √ √ √ √ x √ √ x x √
38 Syauqi Ramadhan L 06-04-2022 N 7 H √ √ √ √ x √ √ x x √
39 Aina Mardiyah P 05-11-2020 K 23 K √ √ √ √ √ √ √ √ x √
40 M. Zidni Huda L 06-11-2020 N 23 H √ √ √ x x √ √ √ x √
41 3317062911200001 M.Chasan Jamil L 29-11-2020 N 23 H √ √ √ x x √ √ √ x √
42 Fatimah Yaqut Fahriyani P 08-01-2021 N 22 H √ √ √ x x √ √ √ x √
43 3317066001210001 Fina Saadah P 20-01-2021 S 21 M √ √ √ x √ √ √ √ x √
44 3317061402210002 M. Idror L 14-02-2021 N 21 H √ √ √ x x √ √ √ x √
45 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 18 H √ √ √ x x √ √ √ x √
46 Aisyah Najla Rosyidah P 15-05-2021 N 18 H √ √ √ x x √ √ √ x √
47 Alifia Nazla Nurul Ilmi P 30-05-2021 N 17 H √ √ √ x x √ √ √ x √
48 Adzkiya Noura Umar P 06-07-2021 N 16 H √ √ √ x x √ √ √ x √
49 Muh. Asyraf Tsaquf L 07-07-2021 K 16 K √ √ √ x √ √ √ √ x √
50 Dina Putri Aulia P 23-07-2021 N 16 H √ √ √ x x √ √ √ x √
51 Sanum Azzarein P 10-08-2021 N 15 H √ √ √ √ x √ √ √ x √
52 Afika Lidya Putri P 28-08-2021 N 15 H √ √ √ x x √ √ √ x √
53 Fatimah Rayla Zara P 31-08-2021 N 15 H √ √ √ x x √ √ √ x √
54 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 14 H √ √ √ x x √ √ √ x √
55 M. Ardiansyah L 02-10-2021 N 13 H √ √ √ √ x √ √ √ x √
56 M. Iqbal L 31-10-2021 N 13 H √ √ √ √ x √ √ x x √
57 Adzkiy Dinillah L 18-12-2021 N 13 H √ √ √ √ x √ √ x x √
58 Nayyira Zuyyina Salsabila P 21-12-2021 N 11 H √ √ √ √ x √ √ x x √
59 M. Ali Imron L 22-01-2022 N 10 H √ √ √ √ x √ √ x x √
60 M. Salman Farisi L 09-03-2022 N 8 H √ √ √ √ x √ √ x x √
61 Zaqiyatun Nisa P 09-03-2022 N 8 H √ √ √ √ x √ √ x x √
62 3317060901210004 Salman Usmani L 09-01-2021 N 22 H √ √ √ x x √ √ √ √ √
63 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 21 H √ √ √ x x √ √ √ x √
64 Humaira Rahma P 03-03-2021 N 19 H √ √ √ x x √ √ √ x √
65 Usman Faqih Abdillah L 25-03-2021 N 19 H √ √ √ x x √ √ x x √
66 Muhammad Kenzo Alvaro L 04-05-2021 N 17 H √ √ √ x x √ √ √ x √
67 Muhammad Faisal Hakim L 05-06-2021 K 17 K √ √ √ √ √ √ √ √ x √
68 Muhammad Mazzin Mujtaba L 25-06-2021 N 16 H √ √ √ x x √ √ √ x √
69 M. Hazin Musaddad L 15-07-2021 K 16 K √ √ √ x √ √ √ √ x √
70 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 15 H √ √ √ x x √ √ √ x √
71 Nur Laila Atiya P 10-08-2021 K 15 K √ √ √ √ √ √ √ x x √
72 Hibatul Maula P 13-11-2021 N 12 H √ √ √ x x √ √ x x √
73 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 12 H √ √ √ x x √ √ x √ √
74 Muhammad Najid Fayyad L 27-11-2021 N 11 H √ √ √ x x √ √ x x √
75 Ahnaf Nufayyi' L 04-01-2022 N 10 H √ √ √ √ x √ √ x x √
76 Naswa Yumna Ramadhani P 22-04-2022 N 7 H √ √ √ √ x √ √ x x √
77 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 22 H √ √ √ x x √ √ √ x √
78 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 22 M √ √ √ √ √ √ √ √ x √
79 Karina Mazaya Dzakiyah P 23-12-2020 N 22 H √ √ √ x x √ √ √ x √
80 Danial Abdul Syakur Asif L 26-12-2020 N 22 H √ √ √ x x √ √ √ x √
81 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 18 H √ √ √ x x √ √ √ x √
82 3317062405210002 Azka Latiful Umam L 24-05-2021 N 18 H √ √ √ √ x √ √ √ x √
83 Asna Khusnin Nada P 25-06-2021 N 16 H √ √ √ √ x √ √ √ x √
84 3317065909210002 Widdatul Ulya P 19-09-2021 N 14 H √ √ √ √ x √ √ √ x √
85 BY. Nurul Maunah L 13-02-2022 N 9 H √ √ √ x x √ √ x x √
86 Umi Habibah P 25-03-2022 N 8 H √ √ √ x x √ √ x x √

Sidorejo, 30 November 2022

 KPM DESA SIDOREJO

Nailis Saadah

B 0 2
S 1
K 12 11
73
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

BULAN : DESEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 K 22 K √ √ √ x √ √ √ √ x √
2 Ahmad Farhan Alalifi L 23-02-2021 N 21 H √ √ √ x x √ √ √ x √
3 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N 21 H √ √ √ x x √ √ √ x √
4 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N 21 H √ √ √ √ x √ √ √ x √
5 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N 21 H √ √ √ x x √ √ √ x √
6 Farha Nisyatul Mazaya P 05-03-2021 N 21 H √ √ √ √ x √ √ √ x √
7 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 K 20 K √ √ √ x √ √ √ √ x √
8 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N 19 H √ √ √ x x √ √ √ x √
9 Yumna Ziyanada Kalisa P 28-04-2021 N 19 H √ √ √ x x √ √ √ x √
10 M. Azmi Alfarizi L 18-05-2021 K 18 K √ √ √ x √ √ √ √ x √
11 Ahmad Mushollin L 19-06-2021 N 17 H √ √ √ √ x √ √ √ x √
12 Maryam Eliza Khasanah P 27-06-2021 N 17 H √ √ √ √ x √ √ √ x √
13 Niko Rafif Pratama L 19-07-2021 N 16 H √ √ √ √ x √ √ √ x √
14 Ahmad Diyaunnas L 06-08-2021 N 16 H √ √ √ √ x √ √ √ x √
15 Muhammad Rosikhul Ulum L 07-08-2021 N 16 H √ √ √ x x √ √ √ x √
16 Laila Wasiatun Maghfiroh L 12-09-2021 N 15 H √ √ √ x x √ √ √ x √
17 Muhammad Syadid L 13-09-2021 N 15 H √ √ √ √ x √ √ √ x √
18 Farel Ahmad Fatian L 18-09-2021 N 15 H √ √ √ x x √ √ √ x √
19 Seva Tia Azzahra P 18-09-2021 N 15 H √ √ √ √ x √ √ √ x √
20 Muhammad Muhtar Alhaq L 01-10-2021 N 14 H √ √ √ x x √ √ x x √
21 Fatimah Tsuroyya Fawaiq P 06-10-2021 N 14 H √ √ √ √ x √ √ x x √
22 Muhammad Gibran Lilmuhsinin L 08-11-2021 N 13 H √ √ √ √ x √ √ x x √
23 Adiba Zahrotut Tazkiyah P 09-11-2021 N 13 H √ √ √ x x √ √ x x √
24 M. Dias Arsyad L 09-11-2021 K 13 K √ √ √ √ √ √ √ x x √
25 Muhammad Fathan Alvaro L 04-12-2021 N 12 H √ √ √ √ √ √ √ x x √
26 Kenzu Febrian Alfarizqi L 13-02-2022 N 10 H √ √ √ √ x √ √ x x √
27 Raisa Malinda Ramadhani P 02-04-2022 K 8 K √ √ √ √ √ √ √ x x √
28 Athiqoh Fadhilah P 02-04-2022 N 8 H √ √ √ √ x √ √ x x √
29 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N 22 H √ √ √ x x √ √ √ x √
30 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N 20 H √ √ √ x x √ √ √ x √
31 Qiyana Zahra Athiqoh P 07-05-2021 K 18 K √ √ √ √ √ √ √ √ x √
32 Hilyatun Nisa P 20-10-2021 N 13 H √ √ √ √ √ √ √ √ x √
33 Aisyah Humaira P 20-10-2021 N 13 H √ √ √ √ x √ √ x x √
34 Thifa Ulya P 21-12-2021 N 12 H √ √ √ √ x √ √ x x √
35 Fabian Azmi L 30-12-2021 N 12 H √ √ √ √ x √ √ x x √
36 Syauqi Ramadhan L 06-04-2022 N 8 H √ √ √ √ x √ √ √ x √
37 Fatimah Yaqut Fahriyani P 08-01-2021 N 23 H √ √ √ x x √ √ √ x √
38 3317066001210001 Fina Saadah P 20-01-2021 S 22 M √ √ √ x √ √ √ √ x √
39 3317061402210002 M. Idror L 14-02-2021 N 22 H √ √ √ x x √ √ √ x √
40 3317062007210002 M. Fahriza Akbar L 15-05-2021 N 19 H √ √ √ x x √ √ √ x √
41 Aisyah Najla Rosyidah P 15-05-2021 N 19 H √ √ √ x x √ √ √ x √
42 Alifia Nazla Nurul Ilmi P 30-05-2021 N 18 H √ √ √ x x √ √ √ x √
43 Adzkiya Noura Umar P 06-07-2021 N 17 H √ √ √ x x √ √ √ x √
44 Muh. Asyraf Tsaquf L 07-07-2021 K 17 K √ √ √ x √ √ √ √ x √
45 Dina Putri Aulia P 23-07-2021 N 17 H √ √ √ x x √ √ √ x √
46 Sanum Azzarein P 10-08-2021 N 16 H √ √ √ √ x √ √ √ x √
47 Afika Lidya Putri P 28-08-2021 N 16 H √ √ √ x x √ √ √ x √
48 Fatimah Rayla Zara P 31-08-2021 N 16 H √ √ √ x x √ √ √ x √
49 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N 15 H √ √ √ x x √ √ √ x √
50 M. Ardiansyah L 02-10-2021 N 14 H √ √ √ √ x √ √ √ x √
51 M. Iqbal L 31-10-2021 N 14 H √ √ √ √ x √ √ x x √
52 Adzkiy Dinillah L 18-12-2021 N 14 H √ √ √ √ x √ √ x x √
53 Nayyira Zuyyina Salsabila P 21-12-2021 N 12 H √ √ √ √ x √ √ x x √
54 M. Ali Imron L 22-01-2022 N 11 H √ √ √ √ x √ √ x x √
55 M. Salman Farisi L 09-03-2022 N 9 H √ √ √ √ x √ √ x x √
56 Zaqiyatun Nisa P 09-03-2022 N 9 H √ √ √ √ x √ √ x x √
57 Roiya Maimunah P 14-10-2022 N 3 H √ √ √ √ x √ √ x x x
58 3317060901210004 Salman Usmani L 09-01-2021 N 23 H √ √ √ x x √ √ √ √ √
59 3317064902210001 Isti Radiati Aliya P 09-02-2021 N 22 H √ √ √ x x √ √ √ x √
60 Humaira Rahma P 03-03-2021 N 20 H √ √ √ x x √ √ √ x √
61 Usman Faqih Abdillah L 25-03-2021 N 20 H √ √ √ x x √ √ x x √
62 Muhammad Kenzo Alvaro L 04-05-2021 N 18 H √ √ √ x x √ √ √ x √
63 Muhammad Faisal Hakim L 05-06-2021 K 18 K √ √ √ √ √ √ √ √ x √
64 Muhammad Mazzin Mujtaba L 25-06-2021 N 17 H √ √ √ x x √ √ √ x √
65 M. Hazin Musaddad L 15-07-2021 K 17 K √ √ √ x √ √ √ √ x √
66 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N 16 H √ √ √ x x √ √ √ x √
67 Nur Laila Atiya P 10-08-2021 K 16 K √ √ √ √ √ √ √ x x √
68 Hibatul Maula P 13-11-2021 N 13 H √ √ √ x x √ √ x x √
69 Muhammad Aditia Zidan Arrafi L 15-11-2021 N 13 H √ √ √ x x √ √ x √ √
70 Muhammad Najid Fayyad L 27-11-2021 N 12 H √ √ √ x x √ √ x x √
71 Ahnaf Nufayyi' L 04-01-2022 N 11 H √ √ √ √ x √ √ x x √
72 Naswa Yumna Ramadhani P 22-04-2022 N 8 H √ √ √ √ x √ √ x x √
73 3317060512200001 Ahmad Arsyad Yusuf L 05-12-2020 N 23 H √ √ √ x x √ √ √ x √
74 3317066712200002 Siti Atiyatul Khoiriyah L 27-12-2020 K 23 M √ √ √ √ √ √ √ √ x √
75 Karina Mazaya Dzakiyah P 23-12-2020 N 23 H √ √ √ x x √ √ √ x √
76 Danial Abdul Syakur Asif L 26-12-2020 N 23 H √ √ √ x x √ √ √ x √
77 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N 19 H √ √ √ x x √ √ √ x √
78 3317062405210002 Azka Latiful Umam L 24-05-2021 N 19 H √ √ √ √ x √ √ √ x √
79 Asna Khusnin Nada P 25-06-2021 N 17 H √ √ √ √ x √ √ √ x √
80 3317065909210002 Widdatul Ulya P 19-09-2021 N 15 H √ √ √ √ x √ √ √ x √
81 BY. Nurul Maunah L 13-02-2022 N 10 H √ √ √ x x √ √ x x √
82 Umi Habibah P 25-03-2022 N 9 H √ √ √ x x √ √ x x √

Sidorejo, 31 DESEMBER 2022

KPM DESA SIDOREJO
 Nailis Saadah

B 0 2
S 1
K 11 10
70
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

JANUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060302210001 Muhammad Ubaidilah Majid L 03-02-2021 K #VALUE! K √ √ √ √ √ √ √ √ x √
2 Ahmad Farhan Alalifi L 23-02-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
3 3317062402210001 Boy Afkar Nurdiansyah L 24-02-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
4 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
5 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 Farha Nisyatul Mazaya P 05-03-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
7 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
8 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
9 3317066804210001 Yumna Ziyanada Kalisa P 28-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
10 3317061805210001 M. Azmi Alfarizi L 18-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
11 Ahmad Mushollin L 19-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
12 Maryam Eliza Khasanah P 27-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
13 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
14 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
15 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
16 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
17 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
18 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
19 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
20 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
21 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
22 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
23 3317064911210001 Adiba Zahrotut Tazkiyah P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
24 M. Dias Arsyad L 09-11-2021 K #VALUE! K √ √ √ √ √ √ √ √ x √
25 Muhammad Fathan Alvaro L 04-12-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
26 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
27 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ √ x √ √ √ x √
28 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ √ x √ √ √ x √
29 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ √ x √ √ √ x √
30 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ √ x √ √ √ x √
31 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ √ x √ √ √ x x
32 Gania Giyara Assabya P 9/15/2022 N 18 H √ √ √ √ x √ √ √ x x
33 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
34 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ x √
35 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x x
36 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x x
37 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ x x x
38 A.Nawaf Wafi L 10/1/2022 N 18 H √ √ √ √ x √ √ x x √
39 Athiqoh Fadhilah P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
40 3317060602210001 Abdul Qadir Kafa Bili L 06-02-2021 N #VALUE! H √ √ √ x x √ √ √ x √
41 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
42 3317064705210001 Qiyana Zahra Athiqoh P 07-05-2021 K #VALUE! K √ √ √ √ √ √ √ √ x √
43 3317066010210002 Hilyatun Nisa P 20-10-2021 S #VALUE! M √ √ √ √ √ √ √ √ x √
44 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! N √ √ √ x x √ √ √ x √
45 3317066512210003 Thifa Ulya P 21-12-2021 K #VALUE! K √ √ √ √ x √ √ √ x √
46 Fabian Azmi L 30-12-2021 K #VALUE! K √ √ √ √ x √ √ √ x √
47 3317065503220002 Fatimatuzzahro P 3/15/2022 K 24 K √ √ √ √ x √ √ √ x √
48 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ √ x √ √ √ x √
49 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ √ x √ √ √ x x
50 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x x
51 Muh.Thuba Fahri Maulidi L 10/17/2022 K 17 K √ √ √ √ x √ √ √ x x
52 Chanindliya Chalwatus Z P 12/28/2022 N 15 H √ √ √ x x √ √ √ x x
53 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
54 3317066001210001 Fina Saadah P 20-01-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
55 3317061402210002 M. Idror L 14-02-2021 N #VALUE! H √ √ √ x x √ √ √ x √
56 3317062007210002 M. Fahriza Akbar L 15-05-2021 K #VALUE! K √ √ √ x x √ √ √ x √
57 Aisyah Najla Rosyidah P 15-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
58 Adzkiya Noura Umar P 06-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
59 Muh. Asyraf Tsaquf L 07-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
60 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
61 Afika Lidya Putri P 28-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
62 Fatimah Rayla Zara P 31-08-2021 K #VALUE! K √ √ √ x x √ √ √ x √
63 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
64 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
65 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
66 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
67 Nayyira Zuyyina Salsabila P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
68 3317065103210001 Bahiyyah Mahmudah P 3/11/2021 N 36 H √ √ √ x x √ √ √ x √
69 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
70 M. Salman Farisi L 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
71 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
72 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
73 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x x
74 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x x
75 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ x √
76 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x x
77 3317060405220001 M.Ainul Y akin L 5/4/2022 N 22 H √ √ √ x x √ √ √ x √
78 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ x √
79 Khadijah P 10/22/2022 N 17 H √ √ √ x x √ √ x x x
80 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ x x x
81 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x x
82 3317064902210001 Isti Radiati Aliya P 09-02-2021 N #VALUE! H √ √ √ x x √ √ √ x √
83 Humaira Rahma P 03-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
84 Usman Faqih Abdillah L 25-03-2021 N #VALUE! H √ √ √ x x √ √ x x √
85 3317060405210001 Muhammad Kenzo Alvaro L 04-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
86 Muhammad Faisal Hakim L 05-06-2021 K #VALUE! K √ √ √ √ √ √ √ √ x √
87 Muhammad Mazzin Mujtaba L 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
88 M. Hazin Musaddad L 15-07-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
 89 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
90 Nur Laila Atiya P 10-08-2021 K #VALUE! K √ √ √ √ √ √ √ √ x √
91 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
92 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
93 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
94 Ahnaf Nufayyi' L 04-01-2022 K #VALUE! K √ √ √ x x √ √ √ x √
95 Naswa Yumna Ramadhani P 22-04-2022 K #VALUE! K √ √ √ x x √ √ √ x √
96 Kanabi Hafiya L 6/4/2022 N 21 H √ √ √ x x √ √ x x √
97 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ x x x
98 Nafahat Fahira Sarmada P 9/27/2022 N 18 H √ √ √ x x √ √ x x x
99 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ x x
100 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
101 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
102 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
103 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ x x
104 Hanin Roihanah P 6/28/2022 N 21 H √ √ √ x x √ √ √ x √
105 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x x
106 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x x
107 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x x
108 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
109 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x x
110 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
111 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x x
112 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
113 3317062405210002 Azka Latiful Umam L 24-05-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
114 Asna Khusnin Nada P 25-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
115 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ √ x √ √ √ x √

Sidorejo, 31 Januari 2023

KPM DESA SIDOREJO
 Qoriatul Afwanah

B 0 1
S 1
K 18 18
95
x
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

FEBRUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060203210001 Muhammad Alfatar Rizqy L 02-03-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
2 3317060203210002 Muhammad Arsya Alwi Alfaqih L 02-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317062103210002 Ahmad Alwi Zuhdi L 21-03-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
4 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 3317066804210001 Yumna Ziyanada Kalisa P 28-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 3317061805210001 M. Azmi Alfarizi L 18-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
7 Ahmad Mushollin L 19-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
8 Maryam Eliza Khasanah P 27-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
9 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
10 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
11 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
12 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
13 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
14 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
15 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
16 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
17 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
18 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
19 3317064911210001 Adiba Zahrotut Tazkiyah P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
20 3317062011210004 M. Dias Arsyad L 09-11-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
21 Muhammad Fathan Alvaro L 04-12-2021 K #VALUE! H √ √ √ x √ √ √ √ x √
22 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
23 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
24 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
25 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
26 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ x √
27 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ x x
28 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x x
29 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x x
30 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
31 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
32 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
33 Nailul mafalih L 6/10/2021 K 33 H √ √ √ x √ √ √ √ √ √
34 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
35 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ x √
36 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x x
37 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x x
38 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ x x
39 3317066403210002 Aleesya Ainara Prameswari P 24-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
40 3317064705210001 Qiyana Zahra Athiqoh P 07-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
41 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! M √ √ √ x √ √ √ √ x √
42 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! N √ √ √ x x √ √ √ x √
43 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! K √ √ √ x x √ √ √ x √
44 Fabian Azmi L 30-12-2021 N #VALUE! K √ √ √ x x √ √ √ x √
45 3317065503220002 Fatimatuzzahro P 3/15/2022 K 24 K √ √ √ x √ √ √ √ x √
46 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
47 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
48 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
49 Muh.Thuba Fahri Maulidi L 10/17/2022 N 17 K √ √ √ x x √ √ √ x x
50 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
51 3317062007210002 M. Fahriza Akbar L 15-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
52 3317065505210001 Aisyah Najla Rosyidah P 15-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
53 3317064607210001 Adzkiya Noura Umar P 06-07-2021 K #VALUE! H √ √ √ x √ √ √ √ x √
54 Muh. Asyraf Tsaquf L 07-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
55 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
56 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! H √ √ √ x √ √ √ √ x √
57 Fatimah Rayla Zara P 31-08-2021 N #VALUE! K √ √ √ x x √ √ √ x √
58 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
59 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
60 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
61 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
62 3317065103210001 Bahiyyah Mahmudah P 3/11/2021 N 36 H √ √ √ x x √ √ √ x √
63 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
64 3317060903220001 M. Salman Farisi L 09-03-2022 K #VALUE! H √ √ √ x √ √ √ √ √ √
65 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
66 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
67 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x x
68 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x x
69 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x x
70 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ x √
71 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x x
72 3317060405220001 M.Ainul Y akin L 5/4/2022 K 22 H √ √ √ x √ √ √ √ x √
73 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ x √
74 Khadijah P 10/22/2022 N 17 H √ √ √ x x √ √ x x x
75 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x x
76 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x x
77 Humaira Rahma P 03-03-2021 N #VALUE! H √ √ √ x x √ √ √ x √
78 Usman Faqih Abdillah L 25-03-2021 N #VALUE! H √ √ √ x x √ √ x x √
79 3317060405210001 Muhammad Kenzo Alvaro L 04-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
80 Muhammad Faisal Hakim L 05-06-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
81 Muhammad Mazzin Mujtaba L 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
82 M. Hazin Musaddad L 15-07-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
83 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
84 Nur Laila Atiya P 10-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
85 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
86 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
87 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
88 Ahnaf Nufayyi' L 04-01-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
 89 Naswa Yumna Ramadhani P 22-04-2022 N #VALUE! K √ √ √ x x √ √ √ x √
90 Kanabi Hafiya L 6/4/2022 N 21 H √ √ √ x x √ √ x x √
91 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x x
92 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 K 18 H √ √ √ x √ √ √ √ x x
93 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ x x
94 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ x x x
95 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x x
96 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
97 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
98 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
99 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
100 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ x
101 Hanin Roihanah P 6/28/2022 N 21 H √ √ √ x x √ √ √ x √
102 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x x
103 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x x
104 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x x
105 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
106 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x x
107 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
108 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x x
109 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
110 3317062405210002 Azka Latiful Umam L 24-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
111 Asna Khusnin Nada P 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
112 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 28 Februari 2023

KPM DESA SIDOREJO

Qoriatul Afwanah
B 0 1
S 0
K 18 16
94
x
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

MARET
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317065304210001 Andin Fera Ramadhani P 13-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
2 3317066804210001 Yumna Ziyanada Kalisa P 28-04-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317061805210001 M. Azmi Alfarizi L 18-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
4 Ahmad Mushollin L 19-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
5 Maryam Eliza Khasanah P 27-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
6 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
7 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
9 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
10 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
11 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
12 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
13 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
14 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
15 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
16 3317064911210001 Adiba Zahrotut Tazkiyah P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
17 3317062011210004 M. Dias Arsyad L 09-11-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
18 Muhammad Fathan Alvaro L 04-12-2021 N #VALUE! H √ √ √ x √ √ √ √ x √
19 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
20 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
21 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
22 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
23 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ x √
24 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
25 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x x
26 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x x
27 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
28 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
29 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
30 Nailul mafalih L 6/10/2021 N 33 H √ √ √ x x √ √ √ √ √
31 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
32 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
33 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ x √
34 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x x
35 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
36 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ x x
37 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ x
38 3317064705210001 Qiyana Zahra Athiqoh P 07-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
39 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
40 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
41 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
42 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
43 3317065503220002 Fatimatuzzahro P 3/15/2022 K 24 K √ √ √ x √ √ √ √ x √
44 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
45 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
46 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
47 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
48 3317062007210002 M. Fahriza Akbar L 15-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
49 3317065505210001 Aisyah Najla Rosyidah P 15-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
50 3317064607210001 Adzkiya Noura Umar P 06-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
51 Muh. Asyraf Tsaquf L 07-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
52 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
53 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
54 Fatimah Rayla Zara P 31-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
55 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
56 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
57 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
58 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
59 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
60 3317060903220001 M. Salman Farisi L 09-03-2022 K #VALUE! K √ √ √ x √ √ √ √ √ √
61 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
62 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
63 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
64 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x x
65 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x x
66 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
67 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x x
68 3317060405220001 M.Ainul Y akin L 5/4/2022 K 22 K √ √ √ x √ √ √ √ x √
69 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
70 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x x
71 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x x
72 3317064304210003 Humaira Rahma P 4/3/2021 N 36 H √ √ √ x x √ √ √ x √
73 3317060405210001 Muhammad Kenzo Alvaro L 04-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
74 Muhammad Faisal Hakim L 05-06-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
75 Muhammad Mazzin Mujtaba L 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
76 M. Hazim Musaddad L 15-07-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
77 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
78 3317061008210002 Nur Laila Atiya P 10-08-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
79 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
80 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
81 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
82 Ahnaf Nufayyi' L 04-01-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
83 Naswa Yumna Ramadhani P 22-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
84 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x x
85 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 K 18 K √ √ √ x √ √ √ √ √ x
86 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ x
87 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x x
88 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x x
 89 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
90 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
91 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
92 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
93 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
94 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x x
95 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x x
96 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
97 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
98 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x x
99 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
100 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x x
101 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
102 3317062405210002 Azka Latiful Umam L 24-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
103 Asna Khusnin Nada P 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
104 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 31 Maret 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 0
S 0
K 15 15
89
x
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

APRIL
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061805210001 M. Azmi Alfarizi L 18-05-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
2 Ahmad Mushollin L 19-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
3 Maryam Eliza Khasanah P 27-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
4 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
5 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
7 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
9 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
10 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
11 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
12 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
13 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
14 3317064911210001 Adiba Zahrotut Tazkiyah P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
15 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
16 Muhammad Fathan Alvaro L 04-12-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
17 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
18 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
19 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
20 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
21 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ x √
22 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
23 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x x
24 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x x
25 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
26 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
27 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
28 Nailul mafalih L 6/10/2021 N 33 H √ √ √ x x √ √ √ √ √
29 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
30 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
31 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ x √
32 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
33 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
34 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ x √
35 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ x
36 3317064705210001 Qiyana Zahra Athiqoh P 07-05-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
37 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
38 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
39 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
40 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
41 3317065503220002 Fatimatuzzahro P 3/15/2022 K 24 K √ √ √ x √ √ √ √ x √
42 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
43 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
44 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
45 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
46 3317062007210002 M. Fahriza Akbar L 15-05-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
47 3317065505210001 Aisyah Najla Rosyidah P 15-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
48 3317064607210001 Adzkiya Noura Umar P 06-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
49 Muh. Asyraf Tsaquf L 07-07-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
50 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
51 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
52 Fatimah Rayla Zara P 31-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
53 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
54 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
55 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
56 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
57 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
58 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
59 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
60 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
61 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
62 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x x
63 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x x
64 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
65 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
66 3317060405220001 M.Ainul Y akin L 5/4/2022 K 22 K √ √ √ x √ √ √ √ x √
67 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
68 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x x
69 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x x
70 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ x x x
71 3317060405210001 Muhammad Kenzo Alvaro L 04-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
72 Muhammad Faisal Hakim L 05-06-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
73 Muhammad Mazzin Mujtaba L 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
74 3317061507210002 M. Hazim Musaddad L 15-07-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
75 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
76 3317061008210002 Nur Laila Atiya P 10-08-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
77 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
78 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
79 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
80 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
81 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
82 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
83 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ x
84 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x x
85 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x x
86 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
87 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
88 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
 89 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
90 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
91 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x x
92 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
93 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
94 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
95 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x √
96 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
97 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x x
98 3317060705210001 Muhammad Hanan Habibillah L 07-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
99 3317062405210002 Azka Latiful Umam L 24-05-2021 N #VALUE! H √ √ √ x x √ √ √ x √
100 Asna Khusnin Nada P 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
101 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 30 April 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 9
S 9
K 7 7
85
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

MEI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Ahmad Mushollin L 19-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
2 Maryam Eliza Khasanah P 27-06-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
3 3317061907210001 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
4 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
7 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
9 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
10 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
11 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
12 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
13 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
14 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
15 Muhammad Fathan Alvaro L 04-12-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
16 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
17 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
18 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
19 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
20 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ x √
21 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
22 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x x
23 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x x
24 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
25 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
26 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
27 Nailul mafalih L 6/10/2021 N 33 H √ √ √ x x √ √ √ √ √
28 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
29 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
30 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ x √
31 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
32 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
33 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ x √
34 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ x
35 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ x x
36 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
37 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
38 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
39 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
40 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 K √ √ √ x √ √ √ √ x √
41 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
42 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
43 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
44 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
45 3317066502230001 Dewi Aminah P 2/25/2023 S 13 M √ √ √ x √ √ √ √ x x
46 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ x
47 3317064607210001 Adzkiya Noura Umar P 06-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
48 Muh. Asyraf Tsaquf L 07-07-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
49 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
50 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
51 Fatimah Rayla Zara P 31-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
52 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
53 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
54 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
55 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
56 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
57 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
58 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
59 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
60 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
61 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
62 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
63 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x x
64 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
65 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
66 3317060405220001 M.Ainul Y akin L 5/4/2022 K 22 K √ √ √ x √ √ √ √ x √
67 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
68 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x x
69 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x x
70 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ x x x
71 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x x
72 Muhammad Faisal Hakim L 05-06-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
73 Muhammad Mazzin Mujtaba L 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
74 3317061507210002 M. Hazim Musaddad L 15-07-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
75 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
76 3317061008210002 Nur Laila Atiya P 10-08-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
77 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
78 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
79 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
80 Naswa Yumna Ramadhani P 4/22/2022 N 23 H √ √ √ x x √ √ √ x √
81 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
82 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
83 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
84 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
85 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x x
86 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x x
87 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
88 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
 89 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
90 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
91 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
92 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
93 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
94 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
95 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
96 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x √
97 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
98 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x x
99 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x x
100 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x x
101 Asna Khusnin Nada P 25-06-2021 N #VALUE! H √ √ √ x x √ √ √ x √
102 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 31 Mei 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 9
S 10
K 5 6
87
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

JUNI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061907210001 Niko Rafif Pratama L 19-07-2021 N #VALUE! H √ √ √ √ x √ √ √ x √
2 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
4 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
7 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
9 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
10 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
11 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
12 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
13 Muhammad Fathan Alvaro L 04-12-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
14 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
15 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
16 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
17 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
18 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ x √
19 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
20 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x x
21 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x x
22 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x x
23 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
24 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
25 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
26 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
27 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
28 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ √ √
29 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
30 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
31 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
32 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ x
33 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ x
34 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
35 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
36 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
37 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
38 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 K √ √ √ x √ √ √ √ x √
39 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
40 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
41 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
42 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
43 3317066502230001 Dewi Aminah P 2/25/2023 S 13 M √ √ √ x √ √ √ √ x x
44 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ x
45 3317064607210001 Adzkiya Noura Umar P 06-07-2021 K #VALUE! K √ √ √ x √ √ √ √ √ √
46 Muh. Asyraf Tsaquf L 07-07-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
47 3317066307210001 Dina Putri Aulia P 23-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
48 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
49 Fatimah Rayla Zara P 31-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
50 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
51 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
52 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
53 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
54 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
55 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
56 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
57 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
58 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
59 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
60 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
61 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x √
62 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
63 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
64 3317060405220001 M.Ainul Y akin L 5/4/2022 K 22 K √ √ √ x √ √ √ √ x √
65 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
66 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
67 Airin Azzahra Alfatunnisa P 12/11/2022 K 15 H √ √ √ x x √ √ x x √
68 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x x
69 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x x
70 3317061507210002 M. Hazim Musaddad L 15-07-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
71 3317066807210001 Aulia Hikmatul Hilmiya P 28-07-2021 N #VALUE! H √ √ √ x x √ √ √ x √
72 3317061008210002 Nur Laila Atiya P 10-08-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
73 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
74 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
75 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
76 Naswa Yumna Ramadhani P 4/22/2022 N 23 H √ √ √ x x √ √ √ x √
77 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
78 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
79 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
80 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
81 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x x
82 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x x
83 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
84 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
85 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x x
86 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x x
87 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
88 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
 89 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
90 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
91 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
92 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
93 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
94 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
95 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x √
96 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x x
97 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x x
98 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x x
99 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √
100 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 30 Juni 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 9
S 10
K 5 5
86
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

JULI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Ahmad Diyaunnas L 06-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
2 Muhammad Rosikhul Ulum L 07-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317065209210001 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
4 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
6 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
7 Muhammad Muhtar Alhaq L 01-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 3317064610210003 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
9 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
10 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
11 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
12 3317060412210001 Muhammad Fathan Alvaro L 04-12-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
13 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
14 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
15 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
16 Raffan Syauqi Arrasya L 2/12/2022 N 25 H √ √ √ x x √ √ √ x √
17 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
18 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
19 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
20 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
21 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x x
22 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
23 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
24 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
25 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
26 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
27 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ √ √
28 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
29 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
30 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
31 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
32 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ x
33 3317066010210002 Hilyatun Nisa P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
34 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
35 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
36 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
37 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
38 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
39 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
40 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
41 Syauqi Ramadhan L 26-04-2022 N #VALUE! H √ √ √ x x √ √ √ x √
42 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x x
43 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ x
44 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 H √ √ √ x x √ √ x x x
45 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x x
46 3317066608210001 Afika Lidya Putri P 28-08-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
47 Fatimah Rayla Zara P 31-08-2021 N #VALUE! H √ √ √ x x √ √ √ x √
48 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
49 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
50 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
51 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
52 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
53 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
54 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
55 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
56 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
57 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
58 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
59 Kenedy Muammar Kadafi L 12/12/2022 K 15 K √ √ √ x √ √ √ √ x √
60 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
61 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
62 3317060405220001 M.Ainul Y akin L 5/4/2022 N 22 H √ √ √ x x √ √ √ x √
63 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
64 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
65 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
66 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x x
67 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x x
68 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x x
69 3317061008210002 Nur Laila Atiya P 10-08-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
70 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
71 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
72 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
73 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 K 23 K √ √ √ x √ √ √ √ x √
74 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
75 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
76 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
77 3317065311220002 Zalfa Azzahra P 11/13/2022 K 16 K √ √ √ x √ √ √ √ √ √
78 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
79 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
80 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
81 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
82 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x x
83 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x x
84 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x x
85 3317066503220001 Umi Habibah P 3/25/2022 N 24 H √ √ √ x x √ √ √ x √
86 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
87 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
88 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
89 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
90 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
91 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
92 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
93 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x √
94 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
95 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x x
96 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x x
97 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x x
98 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √
99 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 31 Juli 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 8
S 8
K 4 4
87
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

AGUSTUS
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317065209210001 Laila Wasiatun Maghfiroh L 12-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
2 3317061309210002 Muhammad Syadid L 13-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317061809210001 Farel Ahmad Fatian L 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
4 Seva Tia Azzahra P 18-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 3317060110210001 Muhammad Muhtar Alhaq L 01-10-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
6 3317064610210003 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
7 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
8 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
9 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
10 3317060412210001 Muhammad Fathan Alvaro L 04-12-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
11 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
12 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
13 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
14 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
15 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
16 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
17 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
18 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
19 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x x
20 Fitriya Lutfatul Khusna P 5/20/2023 N 10 H √ √ √ x x √ √ x x x
21 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
22 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
23 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
24 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
25 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
26 Ahmad musyaroful istifad L 1/23/2022 N 26 H √ √ √ √ x √ √ √ √ √
27 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
28 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
29 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
30 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
31 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
32 3317066010210002 Hilyatun Nisa P 20-10-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
33 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
34 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
35 Fabian Azmi L 30-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
36 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
37 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
38 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
39 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
40 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
41 3317066812220001 Chanindhiya Chalwatuz Zahra P 12/28/2022 N 15 H √ √ √ x x √ √ √ x √
42 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
43 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ x
44 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 H √ √ √ x x √ √ x x x
45 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x x
46 3317060209210001 M. Ubaidillah Rikza L 02-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √
47 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
48 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
49 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
50 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
51 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
52 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
53 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
54 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
55 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
56 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
57 Kenedy Muammar Kadafi L 12/12/2022 K 15 K √ √ √ x √ √ √ √ x √
58 3317065604220001 Zaqiyatun Nisa P 09-03-2022 N #VALUE! H √ √ √ x x √ √ √ √ √
59 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
60 3317060405220001 M.Ainul Y akin L 5/4/2022 N 22 H √ √ √ x x √ √ √ x √
61 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
62 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
63 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
64 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
65 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x x
66 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x x
67 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
68 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
69 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
70 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 K 23 K √ √ √ x √ √ √ √ x √
71 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
72 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
73 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
74 3317065311220002 Zalfa Azzahra P 11/13/2022 K 16 K √ √ √ x √ √ √ √ √ √
75 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
76 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
77 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
78 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
79 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
80 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x x
81 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x x
82 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
83 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
84 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
85 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
86 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
87 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
88 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ x x √
89 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
90 M.Zayyan Inza Al L 10/14/2022 N 17 H √ √ √ x x √ √ x x √
91 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
92 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x x
93 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
94 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
95 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √
96 3317065909210002 Widdatul Ulya P 19-09-2021 N #VALUE! H √ √ √ x x √ √ √ x √

Sidorejo, 31 Agustus 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 12
S 12
K 3 3
81
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

SEPTEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060110210001 Muhammad Muhtar Alhaq L 01-10-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
2 3317064610210003 Fatimah Tsuroyya Fawaiq P 06-10-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
3 Muhammad Gibran Lilmuhsinin L 08-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
4 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
5 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
6 3317060412210001 Muhammad Fathan Alvaro L 04-12-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
7 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
8 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
9 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
10 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
11 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
12 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
13 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
14 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
15 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x x
16 Fitriya Lutfatul Khusna P 5/20/2023 N 10 H √ √ √ x x √ √ x x x
17 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
18 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
19 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
20 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
21 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x x
22 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
23 Ahmad musyaroful istifad L 1/23/2022 S 26 M √ √ √ √ √ √ √ √ √ √
24 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
25 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
26 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
27 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
28 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
29 3317066010210002 Hilyatun Nisa P 20-10-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
30 3317065610210003 Aisyah Humaira P 20-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
31 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
32 Fabian Azmi L 30-12-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
33 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
34 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
35 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
36 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
37 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
38 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
39 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
40 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 H √ √ √ x x √ √ x x x
41 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x x
42 M. Ardiansyah L 02-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
43 3317063110210001 M. Iqbal L 31-10-2021 N #VALUE! H √ √ √ x x √ √ √ x √
44 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
45 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
46 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
47 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
48 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
49 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
50 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
51 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
52 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x √
53 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x x
54 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x x
55 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
56 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
57 3317060405220001 M.Ainul Yakin L 5/4/2022 N 22 H √ √ √ x x √ √ √ x √
58 33170648072200002Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
59 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
60 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
61 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
62 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x x
63 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x x
64 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
65 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
66 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
67 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
68 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 K 23 K √ √ √ x √ √ √ √ x √
69 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
70 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
71 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
72 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
73 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
74 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
75 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
76 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
77 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
78 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
79 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x x
80 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
81 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
82 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
83 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
84 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
85 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
86 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ √ x √
87 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
88 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
89 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
90 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x x
91 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x x
92 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x x
93 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
94 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
95 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 30 September 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 15
S 15
K 2 2
78
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

OKTOBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 Muhammad Gibran Lilmuhsinin L 08-11-2021 K #VALUE! K √ √ √ x √ √ √ √ x √
2 3317064911210001 Adiba Zahrotut Tazkiya P 09-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317062011210004 M. Dias Arsyad L 09-11-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
4 3317060412210001 Muhammad Fathan Alvaro L 04-12-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
5 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
6 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
7 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
8 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
9 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
10 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
11 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
12 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
13 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
14 Fitriya Lutfatul Khusna P 5/20/2023 N 10 H √ √ √ x x √ √ x x x
15 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
16 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
17 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
18 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
19 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x x
20 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 N 10 H √ √ √ x x √ √ √ x x
21 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
22 Ahmad musyaroful istifad L 1/23/2022 S 26 M √ √ √ √ √ √ √ √ √ √
23 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
24 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
25 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
26 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
27 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
28 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ √ √ x
29 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
30 Fabian Azmi L 30-12-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
31 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
32 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
33 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
34 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
35 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
36 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
37 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
38 Umamah Adifa Zuhdiyah P 5/4/2023 K 10 K √ √ √ x √ √ √ x x x
39 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x x
40 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
41 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
42 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
43 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
44 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
45 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
46 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
47 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
48 Kenedy Muammar Kadafi L 12/12/2022 N 15 H √ √ √ x x √ √ √ x √
49 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
50 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x x
51 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x x
52 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
53 3317065410220001 Roya Maimunah P 14-10-2022 N #VALUE! H √ √ √ x x √ √ √ x √
54 3317060405220001 M.Ainul Yakin L 5/4/2022 N 22 H √ √ √ x x √ √ √ x √
55 33170648072200002Fitrotul Kamila P 7/8/2022 N 20 H √ √ √ x x √ √ √ √ √
56 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
57 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
58 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
59 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x √
60 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x x
61 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x x
62 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
63 3317065311210001 Hibatul Maula P 13-11-2021 N #VALUE! H √ √ √ x x √ √ √ √ √
64 3317062711210002 Muhammad Aditia Zidan Arrafi L 15-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
65 3317062711210002 Muhammad Najid Fayyad L 27-11-2021 N #VALUE! H √ √ √ x x √ √ √ x √
66 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
67 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
68 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
69 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
70 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
71 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
72 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
73 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
74 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
75 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
76 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
77 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x x
78 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
79 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
80 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
81 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
82 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
83 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
84 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ √ x √
85 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
86 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
87 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
88 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x √
89 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x x
90 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x x
91 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x x
92 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
93 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
94 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 31 Oktober 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 14
S 14
K 2 2
78
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

NOVEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317060412210001 Muhammad Fathan Alvaro L 04-12-2021 S #VALUE! M √ √ √ x √ √ √ √ √ √
2 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
3 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
4 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
5 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
6 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
7 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
8 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
9 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
10 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
11 Fitriya Lutfatul Khusna P 5/20/2023 N 10 H √ √ √ x x √ √ x x √
12 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
13 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
14 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
15 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
16 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x √
17 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 N 10 H √ √ √ x x √ √ √ x √
18 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
19 Ahmad musyaroful istifad L 1/23/2022 S 26 M √ √ √ √ √ √ √ √ √ √
20 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
21 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
22 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
23 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
24 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
25 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ √ √ x
26 3317066512210003 Thifa Ulya P 21-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
27 Fabian Azmi L 30-12-2021 S #VALUE! M √ √ √ x √ √ √ √ x √
28 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
29 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
30 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
31 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
32 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
33 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
34 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
35 Umamah Adifa Zuhdiyah P 5/4/2023 K 10 K √ √ √ x √ √ √ x x √
36 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x √
37 3317065812210002 Adzkiy Dinillah L 18-12-2021 N #VALUE! H √ √ √ x x √ √ √ x √
38 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
39 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
40 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
41 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
42 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
43 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
44 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
45 Kenedy Muammar Kadafi L 12/12/2022 K 15 K √ √ √ x √ √ √ √ x √
46 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
47 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x √
48 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x x
49 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
50 3317065410220001 Roya Maimunah P 14-10-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
51 3317060405220001 M.Ainul Yakin L 5/4/2022 S 22 M √ √ √ x √ √ √ √ x √
52 33170648072200002Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
53 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
54 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
55 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
56 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x √
57 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x √
58 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x x
59 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
60 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
61 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
62 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
63 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
64 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
65 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
66 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
67 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
68 3317064406220001 Kanabi Hafiya P 6/4/2022 K 21 K √ √ √ x √ √ √ √ x √
69 3317061902230001 M.Zaid Altaf L 2/19/2023 K 13 K √ √ √ x √ √ √ √ x √
70 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
71 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x √
72 3317062808230001 M.Haidar Ali Mutjaba L 8/28/2023 N 7 H √ √ √ x x √ √ √ x x
73 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
74 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
75 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
76 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
77 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
78 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
79 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ √ x √
80 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
81 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
82 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
83 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x √
84 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x √
85 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x x
86 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x x
87 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
88 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
89 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 30 November 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 15
S 15
K 5 5
69
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

DESEMBER
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
2 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
3 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
4 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
5 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
6 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
7 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
8 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
9 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
10 Fitriya Lutfatul Khusna P 5/20/2023 N 10 H √ √ √ x x √ √ x x √
11 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
12 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
13 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
14 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
15 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x √
16 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 N 10 H √ √ √ x x √ √ √ x √
17 Arfah Rosikhoh P 9/30/2023 N 6 H √ √ √ x x √ √ x x x
18 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
19 Ahmad musyaroful istifad L 1/23/2022 S 26 M √ √ √ √ √ √ √ √ √ √
20 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
21 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
22 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
23 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
24 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
25 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ x x √
26 Ayusita Haifa Yumna P 11/8/2023 N 4 H √ √ √ √ x √ √ x x x
27 Ratisa Aninda P 2/14/2022 N 25 H √ √ √ √ x √ √ x x √
28 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
29 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
30 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
31 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
32 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
33 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
34 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
35 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 K √ √ √ x x √ √ x x √
36 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x √
37 3317062201220002 M. Ali Imron L 22-01-2022 N #VALUE! H √ √ √ x x √ √ √ x √
38 3317060903220001 M. Salman Farisi L 09-03-2022 B #VALUE! M √ √ √ x √ √ √ √ √ √
39 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
40 3317063005220002 Muhammad Yusuf L 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
41 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
42 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
43 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
44 Kenedy Muammar Kadafi L 12/12/2022 N 15 K √ √ √ x x √ √ √ x √
45 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
46 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x √
47 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x x
48 M.Ulul Azmi L 8/23/2023 N 7 H √ √ √ x x √ √ x x x
49 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
50 3317065410220001 Roya Maimunah P 14-10-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
51 3317060405220001 M.Ainul Yakin L 5/4/2022 S 22 M √ √ √ x √ √ √ √ x √
52 33170648072200002Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
53 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
54 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
55 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
56 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x √
57 3317062704230002 Attabik Ausafa Umar L 4/27/2023 N 11 H √ √ √ x x √ √ √ x √
58 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x √
59 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
60 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
61 3317060401220002 Ahnaf Nufayyi' L 04-01-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
62 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
63 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
64 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
65 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
66 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
67 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
68 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
69 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
70 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
71 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x √
72 3317062808230001 M.Haidar Ali Mutjaba L 8/28/2023 N 7 H √ √ √ x x √ √ √ x x
73 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
74 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
75 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
76 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
77 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
78 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
79 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ √ x √
80 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
81 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
82 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
83 M.Wafi Mauza L 4/12/2023 N 11 H √ √ √ x x √ √ x x √
84 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x √
85 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x √
86 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x x
87 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
88 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
89 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 31 Desember 2023

KPM DESA SIDOREJO

Qoriatul Afwanah

B 1 13
S 12
K 1 3
73
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

JANUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317061302220003 Kenzu Febrian Alfarizqi L 13-02-2022 N #VALUE! H √ √ √ x x √ √ √ x √
2 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
3 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
4 3317061202220801 Raffan Syauqi Arrasya L 2/12/2022 S 25 M √ √ √ x √ √ √ √ x √
5 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
6 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
7 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
8 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
9 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
10 Fitriya Lutfatul Khusna P 5/20/2023 K 10 K √ √ √ x √ √ √ x x √
11 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
12 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
13 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
14 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
15 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x √
16 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 N 10 H √ √ √ x x √ √ √ x √
17 Arfah Rosikhoh P 9/30/2023 N 6 H √ √ √ x x √ √ x x x
18 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
19 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
20 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
21 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
22 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
23 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
24 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ x x √
25 Ayusita Haifa Yumna P 11/8/2023 N 4 H √ √ √ √ x √ √ x x x
26 3329145402220002 Ratisa Aninda P 2/14/2022 N 25 H √ √ √ √ x √ √ √ x √
27 3317061312230001 M.Gifari Athar L 12/13/2023 N 3 H √ √ √ √ x √ √ √ x x
28 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
29 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
30 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
31 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
32 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
33 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
34 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
35 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 K √ √ √ x x √ √ x x √
36 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x √
37 3317060903220001 M. Salman Farisi L 09-03-2022 B #VALUE! M √ √ √ x √ √ √ √ √ √
38 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
39 3317063005220002 Muhammad Yusuf L 5/30/2022 S 22 H √ √ √ x √ √ √ √ x √
40 3317065206220002 Maymanah P 6/12/2022 N 21 H √ √ √ x x √ √ √ x √
41 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
42 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
43 Kenedy Muammar Kadafi L 12/12/2022 N 15 K √ √ √ x x √ √ √ x √
44 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
45 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x √
46 3317061205230003 M.Faris Sufyan L 5/12/2023 N 10 H √ √ √ x x √ √ √ x √
47 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x x
48 3317062308230001 M.Ulul Azmi L 8/23/2023 N 7 H √ √ √ x x √ √ x x x
49 Mariyam Khalisa P 12/15/2023 N 3 H √ √ √ x x √ √ x x x
50 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
51 3317065410220001 Roya Maimunah P 14-10-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
52 3317060405220001 M.Ainul Yakin L 5/4/2022 S 22 M √ √ √ x √ √ √ √ x √
53 33170648072200002Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
54 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
55 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
56 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
57 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x √
58 3317062704230002 Attabik Ausafa Umar L 4/27/2023 S 11 H √ √ √ x √ √ √ √ x √
59 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x √
60 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
61 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
62 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
63 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
64 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
65 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
66 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
67 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
68 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
69 3317061902230001 M.Zaid Altaf L 2/19/2023 K 13 K √ √ √ x √ √ √ √ x √
70 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
71 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x √
72 3317062808230001 M.Haidar Ali Mutjaba L 8/28/2023 N 7 H √ √ √ x x √ √ √ x x
73 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
74 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
75 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
76 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
77 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
78 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
79 M.Maulana Khalif L 9/9/2022 N 18 H √ √ √ x x √ √ √ x √
80 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
81 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
82 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
83 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x √
84 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x √
85 Afran Syabil Rasyid L 11/21/2023 N 4 H √ √ √ x x √ √ x x x
86 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x √
87 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
88 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
89 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 31 Januari 2024

KPM DESA SIDOREJO

Qoriatul Afwanah

B 1 11
S 12
K 3 5
73
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

FEBRUARI
Umur dan Status Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Umur Hasil

(PAUD)
Badan

Badan
unting) (M/K/H
(Bulan) )

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
2 Mazaya Sya'bani P 3/17/2022 N 24 H √ √ √ x x √ √ √ x √
3 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 N 20 H √ √ √ x x √ √ √ √ √
4 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
5 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
6 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
7 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
8 Fitriya Lutfatul Khusna P 5/20/2023 K 10 K √ √ √ x √ √ √ x x √
9 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
10 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
11 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
12 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
13 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x √
14 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 N 10 H √ √ √ x x √ √ √ x √
15 Arfah Rosikhoh P 9/30/2023 N 6 H √ √ √ x x √ √ x x x
16 3317062911230002 M.Rehan Rafasya L 11/29/2023 N 4 H √ √ √ x x √ √ √ x x
17 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
18 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
19 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
20 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
21 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
22 33170664022230001Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
23 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ x x √
24 Ayusita Haifa Yumna P 11/8/2023 N 4 H √ √ √ √ x √ √ x x x
25 3329145402220002 Ratisa Aninda P 2/14/2022 N 25 H √ √ √ √ x √ √ √ x √
26 3317061312230001 M.Gifari Athar L 12/13/2023 N 3 H √ √ √ √ x √ √ √ x x
27 3317065503220002 Fatimatuzzahro P 3/15/2022 S 24 M √ √ √ x √ √ √ √ x √
28 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
29 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
30 Ammah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
31 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
32 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
33 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
34 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 K √ √ √ x x √ √ x x √
35 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x √
36 3317060903220001 M. Salman Farisi L 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
37 3317065702220001 Aysila Rizqiya Husna P 2/17/2022 N 25 H √ √ √ x x √ √ √ x √
38 3317063005220002 Muhammad Yusuf L 5/30/2022 S 22 M √ √ √ x √ √ √ √ x √
39 3317065206220002 Maymanah P 6/12/2022 S 21 M √ √ √ x √ √ √ √ x √
40 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
41 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
42 3317061212220001 Kenedy Muammar Kadafi L 12/12/2022 N 15 K √ √ √ x x √ √ √ x √
43 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
44 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x √
45 3317061205230003 M.Faris Sufyan L 5/12/2023 N 10 H √ √ √ x x √ √ √ x √
46 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x √
47 3317062308230001 M.Ulul Azmi L 8/23/2023 N 7 H √ √ √ x x √ √ x x √
48 Mariyam Khalisa P 12/15/2023 N 3 H √ √ √ x x √ √ x x x
49 Shanum Rizqinaya P 1/13/2024 N 2 H √ √ √ x x √ √ x x x
50 3317065604220001 Zaqiyatun Nisa P 09-03-2022 S #VALUE! M √ √ √ x √ √ √ √ √ √
51 3317065410220001 Roya Maimunah P 14-10-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
52 3317060405220001 M.Ainul Yakin L 5/4/2022 S 22 M √ √ √ x √ √ √ √ x √
53 33170648072200002Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
54 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
55 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ x x √
56 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
57 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ x x √
58 3317062704230002 Attabik Ausafa Umar L 4/27/2023 S 11 M √ √ √ x √ √ √ √ x √
59 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x √
60 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
61 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
62 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
63 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
64 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
65 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
66 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
67 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
68 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
69 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
70 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
71 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ x x √
72 3317062808230001 M.Haidar Ali Mutjaba L 8/28/2023 K 7 K √ √ √ x √ √ √ √ x x
73 3317066503220001 Umi Habibah P 3/25/2022 S 24 M √ √ √ x √ √ √ √ x √
74 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
75 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
76 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
77 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
78 3317066610220003 Rizka Syabna Kamila P 10/26/2022 N 17 H √ √ √ x x √ √ √ x √
79 M.Maulana Khalif L 9/9/2022 S 18 M √ √ √ x √ √ √ √ x √
80 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
81 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ x x √
82 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
83 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x √
84 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x √
85 Afran Syabil Rasyid L 11/21/2023 N 4 H √ √ √ x x √ √ x x x
86 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ x x √
87 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
88 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
89 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 29 Februari 2024

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 14
S 14
K 3 5
70
 FORMULIR 2.B. PEMANTAUAN BULANAN ANAK 0-23 BULAN

Desa : Sidorejo Kecamatan : Sedan

MARET
Umur dan Status
Indikator Layanan

Jenis Kelamin (L/P)

Tikar
Status Gizi

Konseling Gizi Bagi

Kepemilikan Akses
Pengukuran Tinggi
Tanggal Lahir Anak

Kunjungan Rumah
Pengukuran Berat
Imunisasi Dasar

Jamban Sehat
No No Register (KIA) Nama Anak Anak (Normal/Bur

Kepemilikan

Pengasuhan
Pemberian

Kesehatan
Orang Tua

Akta Lahir
Air Bersih
(Tgl/Bln/Thn) uk/Kurang/St

Jaminan
Hasil

(PAUD)
Badan

Badan
unting) Umur
(M/K/H
(Bulan)
)

a b c d e f g h i j k1 (L) k2 (P) l m n o p q
1 3317062104220002 Athoilah Farhana L 4/21/2022 N 23 H √ √ √ x x √ √ √ x √
2 3317064707220001 Nazilatul Khoirotul Khisan P 7/7/2022 S 20 M √ √ √ x √ √ √ √ √ √
3 3317062908220002 M.Erzan Arkana Elhaq L 8/29/2022 N 19 H √ √ √ x x √ √ √ √ √
4 3317114101230006 Aliya Nadiya Zahra P 1/1/2023 N 15 H √ √ √ x x √ √ √ x √
5 3317064201230002 Khadijah Sanum P 1/2/2023 N 15 H √ √ √ x x √ √ x x √
6 3317065604230001 Kamalatul Aliyah P 4/16/2023 N 11 H √ √ √ x x √ √ x x √
7 3317066005230001 Fitriya Lutfatul Khusna P 5/20/2023 K 10 K √ √ √ x √ √ √ x x √
8 3317060907220002 Muhammad Elzio Pratama L 7/9/2022 N 20 H √ √ √ x x √ √ √ x √
9 Atiqoh Fadilah P 4/2/2022 N 24 H √ √ √ x x √ √ √ x √
10 3317075406220001 Taqiyyah Himmatul Ali P 6/14/2022 N 21 H √ √ √ x x √ √ √ x √
11 3317065509220001 Gania Qiyara Assabya P 9/15/2022 N 18 H √ √ √ x x √ √ √ x √
12 3317060605230001 M.Bahrul Ulum L 5/6/2023 N 10 H √ √ √ x x √ √ √ x √
13 3318135805230001 Sanjula Shiren Aretha P 5/18/2023 K 10 K √ √ √ x √ √ √ √ x √
14 3317067009230001 Arfah Rosikhoh P 9/30/2023 N 6 H √ √ √ x x √ √ x x x
15 3317062911230002 M.Rehan Rafasya L 11/29/2023 N 4 H √ √ √ x x √ √ √ x x
16 3317064204220002 Raisa Malinda Ramadhani P 02-04-2022 N #VALUE! H √ √ √ √ x √ √ √ x √
17 3317066909220002 Ayunda Zahra Maulidia P 9/29/2022 N 18 H √ √ √ √ x √ √ √ x √
18 3317066409220003 Freya Amanda Aurora P 9/24/2022 N 18 H √ √ √ √ x √ √ √ x √
19 3317065810220003 Khibroh DinaZahira P 10/18/2022 N 17 H √ √ √ √ x √ √ √ √ √
20 3317061301120001 Indra Rizqy Pangarep L 1/13/2023 N 14 H √ √ √ √ x √ √ √ √ √
21 33170664022230001 Anisa Ulilwafa Syabana P 2/24/2023 N 13 H √ √ √ √ x √ √ √ √ √
22 Siy'matun Nihaya P 6/8/2023 N 9 H √ √ √ √ x √ √ x x √
23 Ayusita Haifa Yumna P 11/8/2023 N 4 H √ √ √ √ x √ √ x x x
24 3317061312230001 M.Gifari Athar L 12/13/2023 N 3 H √ √ √ √ x √ √ √ x x
25 M.Dafa Alfarizki L 1/18/2024 N 2 H √ √ √ √ x √ √ x x x
26 3317065207220001 Siti Aisyah Mahmadah P 7/12/2022 N 20 H √ √ √ x x √ √ √ x √
27 Awaf Tsabita P 7/30/2022 N 20 H √ √ √ x x √ √ √ x √
28 Aminah Azkiya P 8/1/2022 N 20 H √ √ √ x x √ √ √ x √
29 Syauqi Ramadhan L 26-04-2022 S #VALUE! M √ √ √ x √ √ √ √ x √
30 3317066502230001 Dewi Aminah P 2/25/2023 N 13 H √ √ √ x x √ √ √ x √
31 3317060203230001 M.Hanan Ali Sina L 3/2/2023 N 13 H √ √ √ x x √ √ √ √ √
32 Umamah Adifa Zuhdiyah P 5/4/2023 N 10 K √ √ √ x x √ √ x x √
33 Ainul Wafa L 5/24/2023 N 10 H √ √ √ x x √ √ x x √
34 3317063005220002 Muhammad Yusuf L 5/30/2022 S 22 M √ √ √ x √ √ √ √ x √
35 3317065206220002 Maymanah P 6/12/2022 S 21 M √ √ √ x √ √ √ √ x √
36 3317062409220004 Atif Azam Baihaqi L 9/14/2022 N 18 H √ √ √ x x √ √ √ x √
37 3317064611220001 Zhafira Mutsaqqof Hammadah P 11/6/2022 N 16 H √ √ √ x x √ √ √ x √
38 3317061212220001 Kenedy Muammar Kadafi L 12/12/2022 N 15 K √ √ √ x x √ √ √ x √
39 3317066703230001 Jannah Aliyah P 3/27/2023 N 12 H √ √ √ x x √ √ √ x √
40 3317063004230001 Rafasya Fathan Zidan L 4/30/2023 N 11 H √ √ √ x x √ √ √ x √
41 3317061205230003 M.Faris Sufyan L 5/12/2023 N 10 H √ √ √ x x √ √ √ x √
42 Aurora Jena M P 8/10/2023 N 7 H √ √ √ x x √ √ x x √
43 3317062308230001 M.Ulul Azmi L 8/23/2023 N 7 H √ √ √ x x √ √ x x √
44 Mariyam Khalisa P 12/15/2023 N 3 H √ √ √ x x √ √ x x x
45 Shanum Rizqinaya P 1/13/2024 N 2 H √ √ √ x x √ √ x x x
46 3317065410220001 Roya Maimunah P 14-10-2022 K #VALUE! K √ √ √ x √ √ √ √ x √
47 3317065604220001 Zakiyatun nisa P 4/15/2022 S 23 M √ √ √ x √ √ √ √ √ √
48 3317060405220001 M.Ainul Yakin L 5/4/2022 S 22 M √ √ √ x √ √ √ √ x √
49 33170648072200002 Fitrotul Kamila P 7/8/2022 S 20 M √ √ √ x √ √ √ √ √ √
50 3317064312220002 Salma Ikhtiara Putri P 12/3/2022 N 16 H √ √ √ x x √ √ √ x √
51 3317065112220001 Airin Azzahra Alfatunnisa P 12/11/2022 N 15 H √ √ √ x x √ √ √ x √
52 3317067001230002 alfiyati saadah p 1/30/2023 N 14 H √ √ √ x x √ √ √ x √
53 3317067001230002 M.Wasi' L 4/3/2023 N 12 H √ √ √ x x √ √ √ x √
54 3317062704230002 Attabik Ausafa Umar L 4/27/2023 S 11 M √ √ √ x √ √ √ √ x √
55 3317061806230001 A.Fathir Azzamy L 6/18/2023 N 9 H √ √ √ x x √ √ √ x √
56 3317064802230001 Bahiyyah Salwa P 2/8/2023 N 13 H √ √ √ x x √ √ √ x √
57 3317060311230003 A.Lukman Hakim L 11/3/2023 N 5 H √ √ √ x x √ √ √ x x
58 M.Firza Hasan L 2/10/2024 N 1 H √ √ √ x x √ √ x x x
59 3317066204220002 Naswa Yumna Ramadhani P 4/22/2022 S 23 M √ √ √ x √ √ √ √ x √
60 3317065310220001 Maziya Maulida Kamil P 10/13/2022 N 17 H √ √ √ x x √ √ √ x √
61 3317062709220002 Nafahat Fahira Sarmada P 9/27/2022 S 18 M √ √ √ x √ √ √ √ √ √
62 3317065311220002 Zalfa Azzahra P 11/13/2022 N 16 H √ √ √ x x √ √ √ √ √
63 3317067112220001 Fatimatuzzahra P 12/31/2022 N 15 H √ √ √ x x √ √ √ x √
64 Mariyam Qirti Mutia P 1/12/2023 N 14 H √ √ √ x x √ √ x x √
65 3317060607220001 Azfer Nabhan Alhammada L 7/6/2022 N 20 H √ √ √ x x √ √ √ x √
66 3317064406220001 Kanabi Hafiya P 6/4/2022 N 21 H √ √ √ x x √ √ √ x √
67 3317061902230001 M.Zaid Altaf L 2/19/2023 N 13 H √ √ √ x x √ √ √ x √
68 3317062802230001 Abdul Hadi Almuafa L 2/28/2023 N 13 H √ √ √ x x √ √ √ x √
69 3317061905230002 M.Luthfil Khakim L 5/19/2023 N 10 H √ √ √ x x √ √ √ x √
70 3317062808230001 M.Haidar Ali Mutjaba L 8/28/2023 K 7 K √ √ √ x √ √ √ √ x √
71 3317062808230001 M.Mablugul Mahasin L 10/1/2023 N 6 H √ √ √ x x √ √ √ x x
72 Qirana Firdaus P 6/6/2023 N 9 H √ √ √ x x √ √ x x √
73 '3317066809230001 Maulidah Mahirah Kamilah P 9/28/2023 N 6 H √ √ √ x x √ √ √ x x
74 Aisya Nur Wulandari P 5/30/2022 N 22 H √ √ √ x x √ √ √ x √
75 3317064706220001 Robiatul Adawiyah P 6/7/2022 N 21 H √ √ √ x x √ √ √ x √
76 3317062508220001 M.Zamzami Abdullah L 8/25/2022 N 19 H √ √ √ x x √ √ √ √ √
77 3317062411220001 Naufal Muhammad Hisyam L 11/24/2022 N 16 H √ √ √ x x √ √ √ x √
78 3317066610220003 Rizka Syabna Kamila P 10/26/2022 S 17 M √ √ √ x √ √ √ √ x √
79 3317060909220001 M.Maulana Khalif L 9/9/2022 S 18 M √ √ √ x √ √ √ √ x √
80 3317061806220001 A Razky Ghaiza Khakim L 6/18/2022 N 21 H √ √ √ x x √ √ √ x √
81 3317061410220003 M.Zayyan Inza Al L 10/14/2022 S 17 M √ √ √ x √ √ √ √ x √
82 Abdullah Fatih L 12/27/2022 N 15 H √ √ √ x x √ √ x x √
83 St. Afrin Fahima P 5/13/2023 N 10 H √ √ √ x x √ √ x x √
84 3317064606230001 Alfiyatun Nikmah P 6/6/2023 N 9 H √ √ √ x x √ √ √ x √
85 Afran Syabil Rasyid L 11/21/2023 N 4 H √ √ √ x x √ √ x x x
86 3317064807230001 Mutmainah Bahiyah P 7/8/2023 N 8 H √ √ √ x x √ √ √ x √
87 3317066302230001 Maulidia Fara Rehana P 2/23/2023 N 13 H √ √ √ x x √ √ √ x √
88 M.Rafi Alfarizki L 2/21/2023 N 13 H √ √ √ x x √ √ x x √
89 3317066212220002 Dafeena Keisha P 12/22/2022 N 15 H √ √ √ x x √ √ √ x √

Sidorejo, 31 Maret 2024

KPM DESA SIDOREJO

Qoriatul Afwanah

B 0 13
S 13
K 4 6
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